History-taking and preventive medicine skills among primary care physicians: an assessment using standardized patients

Physiotherapists' awareness and use of red flags for the assessment of low back pain in Saudi Arabia

BACKGROUND

Physiotherapists must identify potential red flags that may impede recovery and function in individuals with low back pain (LBP) or put them at risk.

OBJECTIVES

This study aimed to (1) investigate physiotherapists' awareness and use of red flags for individuals with LBP in Saudi Arabia and (2) identify factors associated with their awareness and use of LBP red flags.

METHODS

This cross-sectional study collected data using an anonymous online questionnaire (February-July 2023). It included physiotherapists working in private/public hospitals in Saudi Arabia. The questionnaire asked about the participants' characteristics, their awareness of LBP red flags, and their use of red flags for LBP assessment.

RESULTS

A total of 643 participating physiotherapists (26.2 ± 3.8 years), 63.8% of whom were females, completed the survey. Most participants (94.4%) had adequate awareness of LBP red flags, and more than half (61%) had good utilization of red flags when assessing individuals with LBP. There was a positive correlation between the physiotherapists' awareness and use of LBP red flags.

CONCLUSION

The majority of the participating physiotherapists in Saudi Arabia were aware of LBP red flags, and many reported to have good use of red flags in clinical practice when assessing and managing individuals with LBP.

Diagnosing virtual patients: the interplay between knowledge and diagnostic activities

Clinical reasoning theories agree that knowledge and the diagnostic process are associated with diagnostic success. However, the exact contributions of these components of clinical reasoning to diagnostic success remain unclear. This is particularly the case when operationalizing the diagnostic process with diagnostic activities (i.e., teachable practices that generate knowledge). Therefore, we conducted a study investigating to what extent knowledge and diagnostic activities uniquely explain variance in diagnostic success with virtual patients among medical students. The sample consisted of N = 106 medical students in their third to fifth year of university studies in Germany (6-years curriculum). Participants completed professional knowledge tests before diagnosing virtual patients. Diagnostic success with the virtual patients was assessed with diagnostic accuracy as well as a comprehensive diagnostic score to answer the call for more extensive measurement of clinical reasoning outcomes. The three diagnostic activities hypothesis generation, evidence generation, and evidence evaluation were tracked. Professional knowledge predicted performance in terms of the comprehensive diagnostic score and displayed a small association with diagnostic accuracy. Diagnostic activities predicted comprehensive diagnostic score and diagnostic accuracy. Hierarchical regressions showed that the diagnostic activities made a unique contribution to diagnostic success, even when knowledge was taken into account. Our results support the argument that the diagnostic process is more than an embodiment of knowledge and explains variance in diagnostic success over and above knowledge. We discuss possible mechanisms explaining this finding.

Factors That Foster Therapeutic Alliance in Pediatric Sports and Orthopedics: A Systematic Review

Therapeutic alliance has been defined as building rapport between provider and patient in order to enhance patient motivation to improve outcomes. The purpose of this systematic review was to identify factors that patients look for that help build a strong therapeutic alliance in their pediatric sports or orthopedics healthcare provider, to identify if these factors differ across healthcare professions, and to identify any differences in therapeutic alliance between patients and their provider regarding in-person and telehealth visits. Scientific databases were searched from inception until August 2022. The search strategy resulted in 2195 articles with 11 studies included in the final analysis. The main attributes adolescents look for in their pediatric sports healthcare provider were shared decision making and understanding patients' sports and goals. These factors were found to differ among parents, sex, race, and socioeconomic status. The top factors improving therapeutic alliance in telehealth were having an already established relationship with the provider, visits lasting longer than 30 min, and having an English-speaking provider for English-speaking patients. The available literature highlights factors that contribute to the development of a stronger therapeutic alliance in the pediatric sports and orthopedics population. As these factors differ among adolescents, parents, sex, race, and socioeconomic status, this review provides insight in what patients and families look for in their provider when seeking care.

A pilot study of patient satisfaction with a self-completed tablet-based digital questionnaire for collecting the patient's medical history in an emergency department

Background

The increasing popularity and availability of tablet computers raises questions regarding clinical scenarios. This pilot study examined the patient’s satisfaction when using a tablet-based digital questionnaire as a tool for obtaining medical history in an emergency department and to what extent gender, age, technical competence and mother tongue influence the user satisfaction. Patients were asked to complete three consecutive questionnaires: The first questionnaire collected basic epidemiological data to measure past digital usage behaviour, the second questionnaire collected the patient’s medical history, and the third questionnaire assessed the overall perceived user satisfaction when using the tablet-based survey application for medical anamnesis.

Results

Of 111 consenting patients, 86 completed all three questionnaires. In summary, the user evaluation was positive with 97.7% (n = 84) of the patients stating that they had no major difficulties using the digital questionnaire. Only 8.1% (n = 7) of patients reported a preference to fill out a paper-and-pen version on the next visit instead, while 98.8% (n = 85) stated that they would feel confident filling out a digital questionnaire on the next visit. The variables gender, age, mother tongue and/or technical competence did not exert a statistically significant influence towards the defined scales usability, content and overall impression.

Conclusion

In conclusion, self-administered tablet-based questionnaires are widely accepted tools for collecting medical information in the emergency room across all ages and genders, regardless of technical competence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06748-y.

Use of standardised patients in optometry training

Clinical relevance: The ability to articulate clinical findings to patients through effective communication is a key skill in all health-care professions.Background: Unannounced standardised patients (SPs) are successful in measuring quality of clinical care provided by qualified optometrists but have not been used in optometry training. Final-year undergraduate optometry students examine members of the public during primary care clinics observed by visiting clinical tutors (VCTs) who provide individualised feedback, highlighting areas for improvement. This pilot study investigates whether unannounced SPs can be used as an additional resource providing enhanced feedback on communication skills in undergraduate optometry education.Methods: Two SPs received intensive training on reporting on students eye examinations and communication skills through completion of pre-designed checklists for each patient encounter. Each SP presented 16 times as an unannounced patient for routine eye examinations. SPs' comments on communication skills of 32 students during 32 examinations was compared to feedback from 10 VCTs. SPs' performance was monitored to ensure consistency. Evaluation of differences in quality and quantity of feedback provided by SPs and VCTs was performed using thematic analysis and chi-squared tests. Student feedback on the use of SPs was obtained on completion of the study.Results: Qualitative thematic analysis revealed six overarching themes emerging from 64 sets of feedback. SPs gave significantly more feedback, both positive comments and comments with recommendations, than VCTs for the (a) total number of comments for each theme (p = 0.0000) and (b) detail and depth of these comments. Students reported that SPs commented on aspects of communication (e.g., establishing rapport and body language) not noted by VCTs.Conclusions: Unannounced SPs can provide enhanced feedback on communication skills to final-year undergraduate optometry students. Students greatly valued VCTs feedback; however, they felt SPs commented on elements of communication not noted by VCTs.

The Physical-Virtual Patient Simulator: A Physical Human Form With Virtual Appearance and Behavior

INTRODUCTION

We introduce a new type of patient simulator referred to as the Physical-Virtual Patient Simulator (PVPS). The PVPS combines the tangible characteristics of a human-shaped physical form with the flexibility and richness of a virtual patient. The PVPS can exhibit a range of multisensory cues, including visual cues (eg, capillary refill, facial expressions, appearance changes), auditory cues (eg, verbal responses, heart sounds), and tactile cues (eg, localized temperature, pulse).

METHODS

We describe the implementation of the technology, technical testing with healthcare experts, and an institutional review board-approved pilot experiment involving 22 nurse practitioner students interacting with a simulated child in 2 scenarios: sepsis and child abuse. The nurse practitioners were asked qualitative questions about ease of use and the cues they noticed.

RESULTS

Participants found it easy to interact with the PVPS and had mixed but encouraging responses regarding realism. In the sepsis scenario, participants reported the following cues leading to their diagnoses: temperature, voice, mottled skin, attitude and facial expressions, breathing and cough, vitals and oxygen saturation, and appearance of the mouth and tongue. For the child abuse scenario, they reported the skin appearance on the arms and abdomen, perceived attitude, facial expressions, and inconsistent stories.

CONCLUSIONS

We are encouraged by the initial results and user feedback regarding the perceived realism of visual (eg, mottling), audio (eg, breathing sounds), and tactile (eg, temperature) cues displayed by the PVPS, and ease of interaction with the simulator.

Impact of Using a 3D Visual Metaphor Serious Game to Teach History-Taking Content to Medical Students: Longitudinal Mixed Methods Pilot Study

BACKGROUND

History taking is a key component of clinical practice; however, this skill is often poorly performed by students and doctors.

OBJECTIVE

The study aimed to determine whether Metaphoria, a 3D serious game (SG), is superior to another electronic medium (PDF text file) in learning the history-taking content of a single organ system (cardiac).

METHODS

In 2015, a longitudinal mixed methods (quantitative and qualitative) pilot study was conducted over multiple sampling time points (10 weeks) on a group of undergraduate medical students at The University of Auckland Medical School, New Zealand. Assessors involved in the study were blinded to group allocation. From an initial sample of 83, a total of 46 medical students were recruited. Participants were assigned to either a PDF group (n=19) or a game group (n=27). In total, 1 participant left the PDF group after allocation was revealed and was excluded. A total of 24 students in the game group and 14 students in the PDF group completed follow-up 7 weeks later. Using an iterative design process for over a year, with input from a variety of clinical disciplines, a cardiac history-taking game and PDF file were designed and informed by Cognitive Load Theory. Each group completed its intervention in 40 min. A total of 3 levels of Kirkpatrick training evaluation model were examined using validated questionnaires: affective (perception and satisfaction), cognitive (knowledge gains and cognitive load), and behavioral attitudes (Objective Structured Clinical Exam) as well as qualitative assessment. A priori hypotheses were formulated before data collection.

RESULTS

Compared with baseline, both groups showed significant improvement in knowledge and self-efficacy longitudinally (P<.001). Apart from the game group having a statistically significant difference in terms of satisfaction (P<.001), there were no significant differences between groups in knowledge gain, self-efficacy, cognitive load, ease of use, acceptability, or objective structured clinical examination scores. However, qualitative findings indicated that the game was more engaging and enjoyable, and it served as a visual aid compared with the PDF file.

CONCLUSIONS

Students favored learning through utilization of an SG with regard to cardiac history taking. This may be relevant to other areas of medicine, and this highlights the importance of innovative methods of teaching the next generation of medical students.

Management of Metastatic Spinal Cord Compression in Ireland: Are Surgeons Overlooked?

Background

The National Institute of Health and Clinical Excellence (NICE) provide a framework of evidence-based guidelines for the management of metastatic spinal cord compression (MSCC). We aimed to compare our center's provision of service to these best practice guidelines and discuss key shortcomings with their implications for the spinal surgeon.

Methods

Patients with radiologic evidence of MSCC over a 30-month period were identified using the hospital electronic radiological database. A chart review was performed analyzing MSCC management.

Results

Forty-one patients were identified. Pain was the most common presenting complaint, occurring in 76% of patients. Radiotherapy alone was the most common therapy employed (93% of patients). A surgical opinion was sought for 51% of patients. Histological diagnosis of the causative lesion occurred in 5 patients from surgical specimens.

Conclusions

Incongruities between NICE guidelines and our practice exist. Early involvement of the spinal surgical services needs to be encouraged. Establishing a histological diagnosis of the spinal lesion should be seen as of therapeutic importance.

Step Up-Not On-The Step 2 Clinical Skills Exam: Directors of Clinical Skills Courses (DOCS) Oppose Ending Step 2 CS

Recently, a student-initiated movement to end the United States Medical Licensing Examination Step 2 Clinical Skills and the Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation has gained momentum. These are the only national licensing examinations designed to assess clinical skills competence in the stepwise process through which physicians gain licensure and certification. Therefore, the movement to end these examinations and the ensuing debate merit careful consideration. The authors, elected representatives of the Directors of Clinical Skills Courses, an organization comprising clinical skills educators in the United States and beyond, believe abolishing the national clinical skills examinations would have a major negative impact on the clinical skills training of medical students, and that forfeiting a national clinical skills competency standard has the potential to diminish the quality of care provided to patients. In this Perspective, the authors offer important additional background information, outline key concerns regarding the consequences of ending these national clinical skills examinations, and provide recommendations for moving forward: reducing the costs for students, exploring alternatives, increasing the value and transparency of the current examinations, recognizing and enhancing the strengths of the current examinations, and engaging in a national dialogue about the issue.

The Behavioral Definitions of "Having Sex With a Man" and "Having Sex With a Woman" Identified by Women Who Have Engaged in Sexual Activity With Both Men and Women

A sizable minority of women report lifetime sexual behavior with both men and women. In the present study, a multinational sample of women who reported genital contact with at least one man and one woman in their lifetime (N = 2,751) were asked to provide their behavioral definitions of "having sex with a woman" and "having sex with a man." Replicating previous research, participants were asked "Would you say you 'had sex' with a woman/man if the most intimate behavior you engaged in with her/him was …" followed by a list of behaviors that differed based on the hypothetical partner gender. While most participants indicated that they would consider "having had sex" if they engaged in a variety of behaviors, behaviors involving genital contact were most often included within the participants' definitions of having sex, regardless of partner gender. The percentage of behaviors included in the participants' definitions of having sex with a woman (M = 59.40%, SD = 20.77%) was higher than the percentage of behaviors included in their definition of having sex with a man (M = 37.26%, SD = 28.97%). Broadening our understanding of "having sex" for individuals with diverse sexual experiences may have important implications for clinicians and researchers.

Are simulated patients effective in facilitating development of clinical competence for healthcare students? A scoping review

Background

The need to evaluate the effectiveness of SPs in improving clinical competence has attracted a heightened interest across the healthcare professions, with some prevailing gaps in their evidence. Using a scoping review approach, this study aims to provide an overview on the effectiveness of SPs in facilitating the development of clinical competence for healthcare students.

Methods

This scoping review applied the first five out of the six-stage methodological framework developed by Levac et al. (Implementation Science 5:69), as follows: 1) Identify the research question; 2) identify relevant studies; 3) study selection; 4) charting the data; and 5) collating, summarising and reporting the results. The search was performed on four databases, including Medline, EMBASE, CINAHL and Scopus.

Results

A total of 33 articles were included in this study (out of 968 identified), comprising of 20 cross-sectional studies, eight randomised controlled trials and five longitudinal studies. The studies were examined and categorised for further discussion in the three domains of clinical competence; technical, non-technical and cognitive skills. Overall, 24 out of 33 studies showed effectiveness of SPs in facilitating students’ clinical competence.

Conclusion

This scoping review serves to provide guidance for future healthcare education development, by illustrating the effectiveness of SPs in improving students’ clinical competence as evidenced in the literature. In doing so, it highlights the potential of SPs in facilitating students’ acquisition of the necessary skills for clinical practice.

How faculty members experience workplace-based assessment rater training: a qualitative study

CONTEXT

Direct observation of clinical skills is a common approach in workplace-based assessment (WBA). Despite widespread use of the mini-clinical evaluation exercise (mini-CEX), faculty development efforts are typically required to improve assessment quality. Little consensus exists regarding the most effective training methods, and few studies explore faculty members' reactions to rater training.

OBJECTIVES

This study was conducted to qualitatively explore the experiences of faculty staff with two rater training approaches - performance dimension training (PDT) and a modified approach to frame of reference training (FoRT) - to elucidate how such faculty development can be optimally designed.

METHODS

In a qualitative study of a multifaceted intervention using complex intervention principles, 45 out-patient resident faculty preceptors from 26 US internal medicine residency programmes participated in a rater training faculty development programme. All participants were interviewed individually and in focus groups during and after the programme to elicit how the training influenced their approach to assessment. A constructivist grounded theory approach was used to analyse the data.

RESULTS

Many participants perceived that rater training positively influenced their approach to direct observation and feedback, their ability to use entrustment as the standard for assessment, and their own clinical skills. However, barriers to implementation and change included: (i) a preference for holistic assessment over frameworks; (ii) challenges in defining competence; (iii) difficulty in changing one's approach to assessment, and (iv) concerns about institutional culture and buy-in.

CONCLUSIONS

Rater training using PDT and a modified approach to FoRT can provide faculty staff with assessment skills that are congruent with principles of criterion-referenced assessment and entrustment, and foundational principles of competency-based education, while providing them with opportunities to reflect on their own clinical skills. However, multiple challenges to incorporating new forms of training exist. Ongoing efforts to improve WBA are needed to address institutional and cultural contexts, and systems of care delivery.

Completeness of pedigree and family cancer history for ovarian cancer patients

OBJECTIVE

To investigate the completeness of pedigree and of number of pedigree analysis to know the acceptable familial history in Korean women with ovarian cancer.

METHODS

Interview was conducted in 50 ovarian cancer patients for obtaining familial history three times over the 6 weeks. The completeness of pedigree is estimated in terms of familial history of disease (cancer), health status (health living, disease and death), and onset age of disease and death.

RESULTS

The completion of pedigree was 79.3, 85.1, and 85.6% at the 1st, 2nd, and 3rd time of interview and the time for pedigree analysis was 34.3, 10.8, and 3.1 minutes, respectively. The factors limiting pedigree analysis were as follows: out of contact with their relatives (38%), no living ancestors who know the family history (34%), dispersed family member because of the Korean War (16%), unknown cause of death (12%), reluctance to ask medical history of relatives (10%), and concealing their ovarian cancer (10%). The percentage of cancers revealed in 1st (2%) and 2nd degree (8%) relatives were increasing through surveys, especially colorectal cancer related with Lynch syndrome (4%).

CONCLUSION

Analysis of pedigree at least two times is acceptable in Korean woman with ovarian cancer from the first study. The completion of pedigree is increasing, while time to take family history is decreasing during three time survey.

Acquisition of HIV by African-born residents of Victoria, Australia: insights from molecular epidemiology

African-born Australians are a recognised "priority population" in Australia's Sixth National HIV/AIDS Strategy. We compared exposure location and route for African-born people living with HIV (PLHIV) in Victoria, Australia, with HIV-1 pol subtype from drug resistance assays and geographical origin suggested by phylogenetic analysis of env gene. Twenty adult HIV positive African-born Victorian residents were recruited via treating doctors. HIV exposure details were obtained from interviews and case notes. Viral RNA was extracted from participant stored plasma or whole blood. The env V3 region was sequenced and compared to globally representative reference HIV-1 sequences in the Los Alamos National Library HIV Database. Twelve participants reported exposure via heterosexual sex and two via iatrogenic blood exposures; four were men having sex with men (MSM); two were exposed via unknown routes. Eight participants reported exposure in their countries of birth, seven in Australia, three in other countries and two in unknown locations. Genotype results (pol) were available for ten participants. HIV env amplification was successful in eighteen cases. HIV-1 subtype was identified in all participants: eight both pol and env; ten env alone and two pol alone. Twelve were subtype C, four subtype B, three subtype A and one subtype CRF02_AG. Reported exposure location was consistent with the phylogenetic clustering of env sequences. African Australians are members of multiple transnational social and sexual networks influencing their exposure to HIV. Phylogenetic analysis may complement traditional surveillance to discern patterns of HIV exposure, providing focus for HIV prevention programs in mobile populations.

Effectiveness of oncogenetics training on general practitioners' consultation skills: a randomized controlled trial

PURPOSE

General practitioners are increasingly called upon to deliver genetic services and could play a key role in translating potentially life-saving advancements in oncogenetic technologies to patient care. If general practitioners are to make an effective contribution in this area, their genetics competencies need to be upgraded. The aim of this study was to investigate whether oncogenetics training for general practitioners improves their genetic consultation skills.

METHODS

In this pragmatic, blinded, randomized controlled trial, the intervention consisted of a 4-h training (December 2011 and April 2012), covering oncogenetic consultation skills (family history, familial risk assessment, and efficient referral), attitude (medical ethical issues), and clinical knowledge required in primary-care consultations. Outcomes were measured using observation checklists by unannounced standardized patients and self-reported questionnaires.

RESULTS

Of 88 randomized general practitioners who initially agreed to participate, 56 completed all measurements. Key consultation skills significantly and substantially improved; regression coefficients after intervention were equivalent to 0.34 and 0.28 at 3-month follow-up, indicating a moderate effect size. Satisfaction and perceived applicability of newly learned skills were highly scored.

CONCLUSION

The general practitioner-specific training proved to be a feasible, satisfactory, and clinically applicable method to improve oncogenetics consultation skills and could be used as an educational framework to inform future training activities with the ultimate aim of improving medical care.

Health care and HIV testing experiences among Black men in the South: implications for "Seek, Test, Treat, and Retain" HIV prevention strategies

Few studies have explored how overall general health care and HIV/STI testing experiences may influence receipt of "Seek, Test, Treat, and Retain" (STTR) HIV prevention approaches among Black men in the southern United States. Using in-depth qualitative interviews with 78 HIV-negative/unknown Black men in Georgia, we explored factors influencing their general health care and HIV/STI testing experiences. The Andersen behavioral model of health care utilization (Andersen model) offers a useful framework through which to examine the general health care experiences and HIV testing practices of Black men. It has four primary domains: Environment, Population characteristics, Health behavior, and Outcomes. Within the Andersen model framework, participants described four main themes that influenced HIV testing: access to insurance, patient-provider communication, quality of services, and personal belief systems. If STTR is to be successful among Black men, improving access and quality of general health care, integrating HIV testing into general health care, promoting health empowerment, and consumer satisfaction should be addressed.

The ABIM's clinical supervision practice improvement module and its effect on faculty's supervisory skills

PURPOSE

Inadequate supervision of medical trainees hampers education and patient care. The authors examine the use of the American Board of Internal Medicine's Clinical Supervision Practice Improvement Module (CS-PIM) to determine whether it facilitated and enhanced faculty's skills in direct observation, providing feedback, identifying errors, and auditing medical records.

METHOD

In this descriptive cohort study, module satisfaction was assessed using a five-point Likert scale. Changes in supervisory skills were measured using a retrospective pre-/postmodule self-assessment; deltas were compared by the Wilcoxon signed rank test.

RESULTS

Between March 2009 and October 2010, 644 faculty completed 647 CS-PIMs. Asked how effective the module was for improving their observation and evaluation skills, 91% rated it excellent, very good, or good. Similarly high percentages of the faculty gave those same ratings to the module for facilitating documenting trainee evaluations, documenting feedback to trainees, reflecting on the summary report, developing an improvement plan, and documenting their self-assessment of supervisory skills. Faculty self-reported improved skills in observation, giving feedback, identifying errors, and auditing medical records.

CONCLUSION

The CS-PIM facilitated and improved faculty skills in the supervision of trainees and led to self-reported changes in supervisory practices. Future research should evaluate trainees' perceptions and the actual impact on quality of care in the teaching setting.

Simulation-based medical teaching and learning

One of the most important steps in curriculum development is the introduction of simulation- based medical teaching and learning. Simulation is a generic term that refers to an artificial representation of a real world process to achieve educational goals through experiential learning. Simulation based medical education is defined as any educational activity that utilizes simulation aides to replicate clinical scenarios. Although medical simulation is relatively new, simulation has been used for a long time in other high risk professions such as aviation. Medical simulation allows the acquisition of clinical skills through deliberate practice rather than an apprentice style of learning. Simulation tools serve as an alternative to real patients. A trainee can make mistakes and learn from them without the fear of harming the patient. There are different types and classification of simulators and their cost vary according to the degree of their resemblance to the reality, or 'fidelity'. Simulation- based learning is expensive. However, it is cost-effective if utilized properly. Medical simulation has been found to enhance clinical competence at the undergraduate and postgraduate levels. It has also been found to have many advantages that can improve patient safety and reduce health care costs through the improvement of the medical provider's competencies. The objective of this narrative review article is to highlight the importance of simulation as a new teaching method in undergraduate and postgraduate education.

Opening the black box of clinical skills assessment via observation: a conceptual model

OBJECTIVES

This study was intended to develop a conceptual framework of the factors impacting on faculty members' judgements and ratings of resident doctors (residents) after direct observation with patients.

METHODS

In 2009, 44 general internal medicine faculty members responsible for out-patient resident teaching in 16 internal medicine residency programmes in a large urban area in the eastern USA watched four videotaped scenarios and two live scenarios of standardised residents engaged in clinical encounters with standardised patients. After each, faculty members rated the resident using a mini-clinical evaluation exercise and were individually interviewed using a semi-structured interview. Interviews were videotaped, transcribed and analysed using grounded theory methods.

RESULTS

Four primary themes that provide insights into the variability of faculty assessments of residents' performance were identified: (i) the frames of reference used by faculty members when translating observations into judgements and ratings are variable; (ii) high levels of inference are used during the direct observation process; (iii) the methods by which judgements are synthesised into numerical ratings are variable, and (iv) factors external to resident performance influence ratings. From these themes, a conceptual model was developed to describe the process of observation, interpretation, synthesis and rating.

CONCLUSIONS

It is likely that multiple factors account for the variability in faculty ratings of residents. Understanding these factors informs potential new approaches to faculty development to improve the accuracy, reliability and utility of clinical skills assessment.

The relationship between direct observation, knowledge, and feedback: results of a national survey

BACKGROUND

Multisource feedback can provide a comprehensive picture of a medical trainee's performance. The utility of a multisource feedback system could be undermined by lack of direct observation and accurate knowledge.

METHOD

The National Board of Medical Examiners conducted a national survey of medical students, interns, residents, chief residents, and fellows to learn the extent to which certain behaviors were observed, to examine beliefs about knowledge of each other's performance, and to assess feedback.

RESULTS

Increased direct observation is associated with the perception of more accurate knowledge, which is associated with increased feedback. Some evaluators provide feedback in the absence of accurate knowledge of a trainee's performance, and others who have accurate knowledge miss opportunities for feedback.

CONCLUSIONS

Direct observation is a key component of an effective multisource feedback system. Medical educators and residency directors may be well advised to establish explicit criteria specifying a minimum number of observations for evaluations.

Observation of resident clinical skills: outcomes of a program of direct observation in the continuity clinic setting

OBJECTIVE

To assess the feasibility of a new multi-institutional program of direct observation and report what faculty observed and the feedback they provided.

METHODS

A program of direct observation of real patient encounters was implemented in 3 pediatric residency programs using a structured clinical observation (SCO) form to document what was observed and the feedback given. Outcome variables included the number of observations made, the nature of the feedback provided, resident attitudes about direct observation before and after implementation, and the response of the faculty.

RESULTS

Seventy-nine preceptors and 145 residents participated; 320 SCO forms were completed. Faculty provided feedback in 4 areas: content, process of the encounter, patient-centered attitudes and behaviors, and interpersonal skills. Feedback was 85% specific and 41% corrective. Corrective feedback was most frequent for physical examination skills. After program implementation, residents reported an increase in feedback and a decrease in discomfort with direct observation; in addition, they agreed that direct observation was a valuable component of their education. Participation rates among faculty were high.

CONCLUSIONS

Direct observation using SCOs results in timely and specific feedback to residents about behaviors rarely observed in traditional precepting models. Resident competency in these clinical skill domains is critical for assessing, diagnosing, and managing patients. The SCO methodology is a feasible way to provide formative feedback to residents about their clinical skills.

Documentation of red flags by physical therapists for patients with low back pain

The comprehensiveness of physical therapists' adherence to the guidelines for red flag documentation for patients with low back pain has not previously been described. Therefore, the purpose of this study was to describe that comprehensiveness. Red flags are warning signs that suggest that physician referral may be warranted. Clinic charts for 160 patients with low back pain seen at 6 outpatient physical therapy clinics were retrospectively reviewed, noting the presence or absence of 11 red flag items. Seven of the 11 red flag items were documented over 98% of the time. Most charts (96.3%) had at least 64% of the red flag items documented. Documentation of red flags was comprehensive in some areas but lacking in others. Red flags that were regularly documented included age over 50, bladder dysfunction, history of cancer, immune suppression, night pain, history of trauma, saddle anesthesia, and lower extremity neurological deficit. The red flags not regularly documented included weight loss, recent infection, and fever/chills. Factors influencing item documentation comprehensiveness are discussed, and suggestions are provided to enhance the completeness of recording patient examination data. The study results provide a red flag documentation benchmark for clinicians working with patients with low back pain and they lay the groundwork for future research.

Sexual behaviour of men that consulted in medical outpatient clinics in Western Switzerland from 2005-2006: risk levels unknown to doctors?

BACKGROUND

To determine male outpatient attenders' sexual behaviours, expectations and experience of talking about their sexuality and sexual health needs with a doctor.

METHODS

A survey was conducted among all male patients aged 18-70, recruited from the two main medical outpatient clinics in Lausanne, Switzerland, in 2005-2006. The anonymous self-administered questionnaire included questions on sexual behaviour, HIV/STI information needs, expectations and experiences regarding discussion of sexual matters with a doctor.

RESULTS

The response rate was 53.0% (N = 1452). The mean age was 37.7 years. Overall, 13.4% of patients were defined as at STI risk--i.e. having not consistently used condoms with casual partners in the last 6 months, or with a paid partner during the last intercourse--regarding their sexual behaviour in the last year. 90.9% would have liked their physician to ask them questions concerning their sexual life; only 61.4% had ever had such a discussion. The multivariate analysis showed that patients at risk tended to have the following characteristics: recruited from the HIV testing clinic, lived alone, declared no religion, had a low level of education, felt uninformed about HIV/AIDS, were younger, had had concurrent sexual partners in the last 12 months. However they were not more likely to have discussed sexual matters with their doctor than patients not at risk.

CONCLUSION

Recording the sexual history and advice on the prevention of the risks of STI should become routine practice for primary health care doctors.

Low back pain and physiotherapy use of red flags: the evidence from Scotland

BACKGROUND

Red flags are recognised as indicators of possible serious spinal pathology, and their use is indicated by numerous guidelines. Similar to other countries worldwide, Scotland lacked a national view about the overall quality of the physiotherapy management of low back pain and the use of red flags. Anecdotal evidence suggested that practice varied considerably.

AIM

To improve the use and documentation of red flags by physiotherapists during the assessment and management of low back pain.

DESIGN

Prospective, multicentred, national data collection and improvement initiative.

SETTING

National Health Service (NHS) health boards in Scotland (n=14) plus two private provider sites.

PARTICIPANTS

One hundred and eighty-six individual NHS provider sites and two private provider sites, with in excess of 360 physiotherapists providing services to low back pain patients.

METHOD

Measurement of documented practice in line with evidence- and consensus-based recommendations from guidelines collected via a web-based tool over two 5-week audit cycles interspersed with an improvement phase over 1 year (2008-2009).

RESULTS

Data from 2147 patients showed improvement in the documentation of all red flags assessed from 33% (n=709) to 65% (n=1396), and improvement in the documentation of cauda equina syndrome from 60% (n=1288) to 84% (n=1804) over the two cycles. Only two regions provided evidence of 100% documentation of all components of cauda equina syndrome, with wide variation across the country.

CONCLUSION

This national initiative resulted in considerable improvement in the documentation of red flags. Despite this, however, one in five patients did not receive optimal management as recommended by guidance. This has significant implications for patient safety and highlights the need for ongoing education of physiotherapists in this area.

Impact of a pre-clinical clinical skills curriculum on student performance in third-year clerkships

BACKGROUND

Research on the outcomes of pre-clinical curricula for clinical skills development is needed to assess their influence on medical student performance in clerkships.

OBJECTIVE

To better understand the impact of a clinical-skills curriculum in the pre-clinical setting on student performance.

DESIGN

We conducted a non-randomized, retrospective, pre-post review of student performance evaluations from 3rd-year clerkships, before and after implementation of a clinical-skills curriculum, the Colleges (2001-2007).

MAIN RESULTS

Comparisons of clerkship performance data revealed statistically significant differences favoring the post-Colleges group in the Internal Medicine clerkship for 9 of 12 clinical-skills domains, including Technical Communication Skills (p < 0.023, effect size 0.16), Procedural Skills (p < 0.031, effect size 0.17), Communication Skills (p < 0.003, effect size 0.21), Patient Relationships (p < 0.003, effect size 0.21), Professional Relationships (p < 0.021, effect size 0.17), Educational Attitudes (p < 0.001, effect size 0.24), Initiative and Interest (p < 0.032, effect size 0.15), Attendance and Participation (p < 0.007, effect size 0.19), and Dependability (p < 0.008, effect size 0.19). Statistically significant differences were identified favoring the post-Colleges group in technical communication skills for three of six basic clerkships (Internal Medicine, Surgery, and Pediatrics).

CONCLUSIONS

Implementation of a pre-clinical fundamental skills curriculum appears to be associated with improved clerkship performance in the 3rd year of medical school, particularly in the Internal Medicine clerkship. Similar curricula, focused on teaching clinical skills in small groups at the bedside with personalized mentoring from faculty members, may improve student performance. Continued efforts are needed to understand how to best prepare students for clinical clerkships and how to evaluate outcomes of similar pre-clinical skills programs.

The content of optometric eye examinations for a young myope with headaches

BACKGROUND

A recent review found standardised patient (SP) methodology to be the gold standard methodology for evaluating clinical care. We used this to investigate the content of optometric eye care for a young myopic patient with headaches suggestive of migraine.

METHODS

We recruited 100 community optometrists who consented to be visited by an unannounced actor for an eye examination and to have that eye examination recorded. The actor received extensive training to enable accurate reporting of the content of the eye examinations, via an audio recording and a checklist completed for each clinical encounter. The actor presented as a 20-year-old student seeking a private eye examination and complaining of symptoms suggestive of migraine headaches. The results of each clinical encounter were recorded on a pre-designed checklist based on evidence-based reviews on headaches, clinical guidelines and the views of an expert panel of optometrists.

RESULTS

The presence of headache was detected in 98% of cases. Eight standard headache questions were considered to be the gold standard for primary care headache investigation. Although none of the optometrists asked all of these questions, 22% asked at least four of the eight questions. Sixty-nine per cent of practitioners asked the patient to seek a medical opinion regarding the headaches. The proportion of the tests recommended by the expert panel that was carried out varied from 33% to 89% and the durations of the eye examination varied from 5 to 50 min.

CONCLUSION

SP encounters are an effective way of measuring clinical care within optometry and should be considered for further comparative measurements of quality of care. As in research using SPs in other healthcare disciplines, our study has highlighted substantial differences between different practitioners in the duration and depth of their clinical investigations. This highlights the fact that not all eye examinations are the same and that there is no such thing as a 'standard sight test'. We recommend that future optometric continuing education could usefully focus on migraine diagnosis and assessment.

Underutilization of information and knowledge in everyday medical practice: evaluation of a computer-based solution

BACKGROUND

The medical history is acknowledged as the sine qua non for quality medical care because recognizing problems is pre-requisite for managing them. Medical histories typically are incomplete and inaccurate, however. We show here that computers are a solution to this issue of information gathering about patients. Computers can be programmed to acquire more complete medical histories with greater detail across a range of acute and chronic issues than physician histories.

METHODS

Histories were acquired by physicians in the usual way and by a computer program interacting directly with patients. Decision-making of what medical issues were queried by computer were made internally by the software, including determination of the chief complaint. The selection of patients was from admissions to the Robert-Bosch-Hospital, Stuttgart, Germany by convenience sampling. Physician-acquired and computer-acquired histories were compared on a patient-by-patient basis for 45 patients.

RESULTS

The computer histories reported 160 problems not recorded in physician histories or slightly more than 3.5 problems per patient. However, physicians but not the computer reported 13 problems. The data show that computer histories reported problems across a range of organ systems, that the problems detected by computer but not physician histories were both acute and chronic and that the computer histories detected a significant number of issues important for preventing further morbidity.

CONCLUSION

A combination of physician and computer-acquired histories, in non-emergent situations, with the latter available to the physician at the time he or she sees the patient, is a far superior method for collecting historical data than the physician interview alone.

An Analysis of the Impact of Gender on Physician Practice Patterns

Through analysis of Community Tracking Study Physician Survey, a nationally representative survey of U.S. physicians, we find that women physicians are significantly less satisfied with time for patients than their male colleagues. Among primary care physicians, about one third of the gender difference is explained by physician attributes, practice characteristics, geographical location and patient profiles. Control variables explain all of the gender gap among specialist physicians. Among primary care physicians, the effects of practice type and perceptions of patient complexity on satisfaction with time for patients are mediated by physician gender. Among specialist physicians, gender interacts with practice ownership and hours spent in medically related activity to determine satisfaction with time for patients.

Primary medical care and reductions in HIV risk behaviors in adults with addictions

Human immunodeficiency virus (HIV) risk behaviors are prevalent in persons with addictions.

OBJECTIVES

To assess whether exposure to primary medical care is associated with decreases in HIV risk behaviors.

DESIGN

Prospective 2-year cohort of 298 adults with addictions.

OUTCOMES

Sex and drug-related HIV risk behaviors, measured by the Risk Assessment Battery.

PREDICTORS

Cumulative number of primary care visits (0, 1, > or = 2). Associations were tested using regression models for correlated data.

RESULTS

In women, receipt of primary care was associated with less sex risk behavior (mean decrease 2.1, p < or = 0.1). Among women and men, > or = 2 primary care visits was associated with lower odds of any drug risk behavior (OR = 0.37, p = 0.03).

CONCLUSIONS

Exposure to primary care can impact HIV risk behavior favorably among adults with addictions.

Family history in pediatric primary care

The family history is a critical element in pediatric medicine and represents the gateway to the molecular age of medicine for both pediatric clinicians and their patients. The pediatric clinician has several opportunities to obtain a family history and multiple clinical and educational uses for that information. Available methods include paper and digital forms, classical pedigrees, online programs, and focused family history at the time of a new diagnosis or problem. Numerous barriers impede the application of family history information to primary pediatric practice. The most common barrier is the limited amount of time the typical primary care encounter allows for its collection. The family history can be used in many facets of pediatric practice: (1) as a diagnostic tool and guide to testing and evaluation; (2) to identify patterns of inheritance; and (3) as a patient-education tool. The most exciting future use of family history is as a tool for public health and preventive medicine. More accurately identifying children at risk for common chronic conditions such as diabetes, asthma, and cardiovascular disease could change the primary care clinician's approach to pediatric medicine.

Improving general practitioners' interviewing skills in managing patients with depression and anxiety: a randomized controlled clinical trial

BACKGROUND

Studies regarding the effectiveness of CME programmes on physicians' behaviour and communication skills showed inconsistent results. Few randomized controlled trials have been conducted in Asia.

METHODS

To evaluate the effectiveness of a 4 2-hour education programme to improve GP interviewing behaviours, 16 general practitioners were randomized to the intervention and control groups, respectively. Physicians assigned to the intervention group received 8 hours of training emphasizing interviewing behaviours in the diagnosis and treatment of depression and generalized anxiety disorders (GDS). Those assigned to the control group did not receive any training until the completion of study. Standardized patients were used to evaluate the performance of physicians. Two consultations before and after enrolling in the education programme were videotaped. Independent evaluations of consultations were made by a trained clinical psychologist and a social worker blinded to the study status of physicians. The rating schedule for the videotapes was based on the tasks listed on the Calgary Cambridge Observation Guide.

RESULTS

The change of score between the intervention and control physicians was significantly different in 'active listening and facilitating patients' response' (p = 0.011) with the intervention physicians having improvement of score. For 'non-verbals', 'understanding patient's perspective' and 'negotiating mutual plan of action', positive change of score in the intervention physicians were seen when compared to that of the control, although the difference did not reach statistical significance (p = 0.06, p = 0.05, p = 0.06, respectively). However, for 'opening', 'structuring the consultation', 'explanation and planning' and 'closure', there were no statistical significant differences between control and intervention group.

CONCLUSIONS

Our results showed that only certain communication skills, such as active listening and facilitating patient's response, can be taught in the management of depression and generalized anxiety disorder (GAD) in Chinese primary care physicians.

Measuring clinical practice

The goals of this paper are to review techniques for measuring clinical practice within healthcare professions and to discuss possible applications of these techniques to primary care optometry. A review of the literature suggests a lack of systematic research investigating standards of clinical practice within optometry. It is argued that evidence-based research to determine the content of typical optometric eye examinations would be valuable for several reasons: to evaluate the service provided to the public by the profession; setting priorities and assessing the outcomes of continuous education and training; to influence governmental and professional policy decisions; National Health Service General Ophthalmic Services issues; the equitable management of clinicolegal matters and consumer complaints; setting appropriate professional guidelines and developing undergraduate training. Evidence-based studies within other healthcare professions have evaluated the content of clinical consultations. The literature reviewed reveals three main approaches: (1) abstraction of medical records, (2) use of clinical vignettes and (3) use of standardized patients (SPs) who present unannounced to clinics. In this review, we compare and contrast the use of these different methods in assessing the content of clinical consultations. It is clear from the literature reviewed that the use of SPs is the 'gold standard' methodology. Clinical vignettes can also provide useful data, especially if computerized.

Ratings of physician communication by real and standardized patients

PURPOSE

Patient ratings of physician's patient-centered communication are used by various specialty credentialing organizations and managed care organizations as a measure of physician communication skills. We wanted to compare ratings by real patients with ratings by standardized patients of physician communication.

METHODS

We assessed physician communication using a modified version of the Health Care Climate Questionnaire (HCCQ) among a sample of 100 community physicians. The HCCQ measures physician autonomy support, a key dimension in patient-centered communication. For each physician, the questionnaire was completed by roughly 49 real patients and 2 unannounced standardized patients. Standardized patients portrayed 2 roles: gastroesophageal disorder reflux symptoms and poorly characterized chest pain with multiple unexplained symptoms. We compared the distribution, reliability, and physician rank derived from using real and standardized patients after adjusting for patient, physician, and standardized patient effects.

RESULTS

There were real and standardized patient ratings for 96 of the 100 physicians. Compared with standardized patient scores, real-patient-derived HCCQ scores were higher (mean 22.0 vs 17.2), standard deviations were lower (3.1 vs 4.9), and ranges were similar (both 5-25). Calculated real patient reliability, given 49 ratings per physician, was 0.78 (95% confidence interval [CI], 0.71-0.84) compared with the standardized patient reliability of 0.57 (95% CI, 0.39-0.73), given 2 ratings per physician. Spearman rank correlation between mean real patient and standardized patient scores was positive but small to moderate in magnitude, 0.28.

CONCLUSION

Real patient and standardized patient ratings of physician communication style differ substantially and appear to provide different information about physicians' communication style.

Connoisseurs of care? Unannounced standardized patients' ratings of physicians

BACKGROUND

Patient satisfaction surveys can be informative, but bias and poor response rates may limit their utility as stable measures of physician performance. Using unannounced standardized patients (SPs) may overcome some of these limitations because their experience and training make them able judges of physician behavior.

OBJECTIVES

We sought to understand the reliability of unannounced SPs in rating primary care physicians when covertly presenting as real patients.

STUDY DESIGN

Data from 2 studies (Patient Centered Communication [PCC]; Social Influences in Practice [SIP]) were included. For the PCC study, 5 SPs made 192 visits to 96 physicians; for the SIP study, 18 SPs made 292 visits to 146 physicians. SPs visits to physicians were randomized, thus avoiding mutual selection bias. Each SP rated 16 to 38 physicians on interpersonal skills (autonomy support: PCC, SIP), technical skills (information gathering: SIP-only), and overall satisfaction (SIP-only). We evaluated SP evaluation consistency (physician vs. total variance rho), and SPs' overall satisfaction with specific dimensions of physician performance.

RESULTS

Scale reliability varied from 0.71 to 0.92. Physician rhos (95% confidence intervals) for autonomy support were 0.40 (0.22-0.58; PCC) and 0.30 (0.14-0.45; SIP); information gathering rho was 0.46 (0.33-0.59; SIP). Overall SP satisfaction rho was 0.47 (0.34-0.60; SIP). SPs varied significantly in adjusted overall satisfaction levels, but not other dimensions.

CONCLUSIONS

These analyses provide some evidence that medical connoisseurship can be learned. When adequately sampled by trained SPs, some physician skills can be reliably measured in community practice settings.

A randomized controlled trial using insinuated standardized patients to assess residents' domestic violence skills following a two-hour workshop

BACKGROUND

Residents feel inadequately trained to treat domestic violence victims.

PURPOSE

The purpose was to assess clinical skills of residents participating in a domestic violence workshop.

METHODS

Twenty-seven internal medicine residents were randomized to receive one of two workshops (domestic violence or control workshop). Standardized patients were trained to two domestic violence cases (depressed; injured). The two cases were randomized and insinuated into each resident's continuity clinic at either 1 to 3 months or more than 3 months after the workshops.

RESULTS

The domestic violence workshop residents did not identify the standardized patients as domestic violence victims any more often than residents participating in the control workshop; 16/25 (64%) versus 13/23 (56%), p=.86. However, domestic violence workshop residents were more likely to score 75% or higher on the domestic violence checklist items compared to control workshop residents; 9/25 (36%) versus 2/23 (9%), p=.04.

CONCLUSIONS

Once a standardized patient was identified in clinic as a domestic violence victim, domestic violence workshop participating residents demonstrated better clinical skills than a control group.

Manualized Communication Interventions to Enhance Palliative Care Research and Training: Rigorous, Testable Approaches

Palliative care practice requires excellent communication between the patient, family, and clinical team. Experts in the field have proposed a variety of communication interventions that can be used in the palliative care setting. However, these interventions are at a high level of generality: the specifics of each intervention are not well codified; the individual steps in each intervention are not easily reproducible and thus not comparable between practitioners; the methods to measure adherence to these communication protocols have not been established; and there is little detail on how to adapt these general interventions to the individual patient and family. Therefore, we lack good evidence for the efficacy of these recommendations. This paper makes the case for development of structured, testable approaches to communication that will inform clinical practice and communication training. To do so, palliative care communication should be conceived as a formal medical and psychosocial intervention-a potential treatment with risks and benefits to be systematically researched and operationalized in the same manner as medication interventions. As we illustrate, psychotherapy research has faced the same challenges in the past and has utilized manualized treatments to meet its goals. Through such approaches, we can begin to address the most basic intervention questions such as protocol efficacy, dose-response, side effects, and the optimal process and content of communication with the patient and family. The advantages of manualized communication approaches; some concepts underlying manual construction; and challenges to extending manualized communication to the palliative care domain are discussed.

A National Survey of Clinic Sexual Histories for Sexually Transmitted Infection and HIV Screening

BACKGROUND

Optimal elements of a sexual history for sexually transmitted infection (STI) and HIV risk assessment remain undefined.

GOAL

The goal of this study was to describe sexual histories in use at STI clinics across the United States.

STUDY

This study consisted of a cross-sectional survey of facilities in cities with populations >200,000 (n = 65). Within each city, a public health STI clinic (71% of the sample) or other STI care facility (29%) was randomly selected and sexual history forms were requested. Information was obtained from 48 clinics (74% response).

RESULTS

Most forms recorded information on symptoms and prior STI (96%), condom use (88%), other contraception (85%), and numbers and gender (83%) of sex partners. Common HIV risk questions were injecting drug use (IDU; 94%), sex for drugs or money (58%), and sex with an HIV-positive or IDU partner (52%). Ascertainment of time during which risks occurred (contact periods) varied from the past 14 days to the past 12 months, with only 38% of clinics using any 1 time period. Few histories (17%) incorporated questions for men who have sex with men (MSM). Only 2 (4%) had space to record information about sexual behaviors by the HIV status of the sex partner. Condom use was infrequently assessed specifically for vaginal and anal sex (13%), and condom use problems were rarely explored (10%). Most forms documented STI/HIV counseling, although few (25%) included specific risk reduction plans.

CONCLUSIONS

Sexual histories are highly variable. Although challenging to accomplish, STI/HIV care, surveillance, and prevention may be improved by developing consensus on core questions to be used in sexual histories.

Fielding incognito standardised patients as 'known' patients in a controlled trial in general practice

BACKGROUND

Incognito standardised patients (SPs) have only been used to represent new patients so far. The few trials with incognito SPs provide little detail on the method used for fielding them.

OBJECTIVE

To establish the feasibility of introducing SPs as 'known' patients (i.e. patients who have previously visited the practice) into practices, to indicate the required practice preparations, and to describe the various aspects of using SPs in a pretest/post-test design.

METHODS

We used incognito SPs as known patients in a controlled trial to assess the practice behaviour of 49 trainees. The SPs received a 2-day training in role playing and completing checklists. We compiled comprehensive practice information folders of each practice to be visited. Real personal data and faked medical data of SPs were inserted in the filing system of each practice to be visited. Apart from SP roles with slightly different reasons-for-encounter and different SPs, the same training protocol, checklists and practice information folders were used in the post-test.

RESULTS

The SPs carried out 287 visits in 50 practices. All practices prepared the patient records for the SP visits in a fairly authentic practice style. Trainees detected the SP in 74 visits. The main reasons for detection were imperfections in patient records and aspects of SP roles or role playing.

CONCLUSION

Fielding incognito SP visits as known patients was feasible but labour-intensive. Preparing the SP patient records and familiarising SPs with the interior of practices represented new elements in the use of SPs. The pretest/post-test format made their use more efficient instead of complicating it.

An evaluation of vignettes for predicting variation in the quality of preventive care

OBJECTIVE

Clinical vignettes offer an inexpensive and convenient alternative to the benchmark method of chart audits for assessing quality of care. We examined whether vignettes accurately measure and predict variation in the quality of preventive care.

DESIGN

We developed scoring criteria based on national guidelines for 11 prevention items, categorized as vaccine, vascular-related, cancer screening, and personal behaviors. Three measurement methods were used to ascertain the quality of care provided by clinicians seeing trained actors (standardized patients; SPs) presenting with common outpatient conditions: 1) the abstracted medical record from an SP visit; 2) SP reports of physician practice during those visits; and 3) physician responses to matching computerized case scenarios (clinical vignettes).

SETTING

Three university-affiliated (including 2 VA) and one community general internal medicine clinics.

PATIENTS/PARTICIPANTS

Seventy-one randomly selected physicians from among eligible general internal medicine residents and attending physicians.

MEASUREMENTS AND MAIN RESULTS

Physicians saw 480 SPs (120 at each site) and completed 480 vignettes. We calculated the proportion of prevention items for each visit reported or recorded by the 3 measurement methods. We developed a multiple regression model to determine whether site, training level, or clinical condition predicted prevention performance for each measurement method. We found that overall prevention scores ranged from 57% (SP) to 54% (vignettes) to 46% (chart abstraction). Vignettes matched or exceeded SP scores for 3 prevention categories (vaccine, vascular-related, and personal behavior). Prevention quality varied by site (from 40% to 67%) and was predicted similarly by vignettes and SPs.

CONCLUSIONS

Vignettes can measure and predict prevention performance. Vignettes may be a less costly way to assess prevention performance that also controls for patient case-mix.

Assessment of patient management skills and clinical skills of practising doctors using computer-based case simulations and standardised patients

CONTEXT

Standardised assessments of practising doctors are receiving growing support, but theoretical and logistical issues pose serious obstacles.

OBJECTIVES

To obtain reference performance levels from experienced doctors on computer-based case simulation (CCS) and standardised patient-based (SP) methods, and to evaluate the utility of these methods in diagnostic assessment.

SETTING AND PARTICIPANTS

The study was carried out at a military tertiary care facility and involved 54 residents and credentialed staff from the emergency medicine, general surgery and internal medicine departments.

MAIN OUTCOME MEASURES

Doctors completed 8 CCS and 8 SP cases targeted at doctors entering the profession. Standardised patient performances were compared to archived Year 4 medical student data.

RESULTS

While staff doctors and residents performed well on both CCS and SP cases, a wide range of scores was exhibited on all cases. There were no significant differences between the scores of participants from differing specialties or of varying experience. Among participants who completed both CCS and SP testing (n = 44), a moderate positive correlation between CCS and SP checklist scores was observed. There was a negative correlation between doctor experience and SP checklist scores. Whereas the time students spent with SPs varied little with clinical task, doctors appeared to spend more time on communication/counselling cases than on cases involving acute/chronic medical problems.

CONCLUSION

Computer-based case simulations and standardised patient-based assessments may be useful as part of a multimodal programme to evaluate practising doctors. Additional study is needed on SP standard setting and scoring methods. Establishing empirical likelihoods for a range of performances on assessments of this character should receive priority.

Family Medicine Residents' Beliefs, Attitudes and Performance with Problem Drinkers

Fifty-six second-year family medicine residents completed a survey on their knowledge and beliefs about problem drinkers. Most residents felt responsible for screening and counseling, were confident in their clinical skills in these areas, and scored well on related knowledge questions. However, only 18% felt that problem drinkers would often respond to brief counseling sessions with physicians while 36% felt that moderate drinking was a reasonable goal for patients with severe alcohol dependence. Residents were then visited by unannounced simulated patients (SPs) presenting with alcohol-induced hypertension or insomnia. Residents detected the SP in 45 out of 104 visits. In the 59 undetected SP visits, residents asked about alcohol consumption in 47 visits (80%), discussed the relationship between alcohol use and the presenting complaint in 37 visits (63%), and recommended a specific weekly consumption in 35 visits (59%). Only 31% offered reduced drinking strategies, and most did not ask about features of alcohol dependence. These results suggest that residents have the fundamental clinical skills required to manage the problem drinker who gives a clear history and is receptive to advice. Educational efforts with residents should focus on the importance of systematic screening, taking an alcohol history under more challenging conditions, identifying the subtler presentations of alcohol problems, counselling the less receptive patient at an earlier stage of change, distinguishing the problem drinker from the alcohol-dependent patient, and offering specific behavioral strategies for the problem drinker.

Improving students' sexual history inquiry and HIV counseling with an interactive workshop using standardized patients

Sexual history and HIV counseling are essential clinical skills. Our project's purpose was to evaluate a standardized patient (SP) educational intervention teaching third-year medical students sexual history taking and HIV counseling. A 4-hour SP workshop was delivered to one-half of the class. Four weeks later, all students engaged in an SP examination including one station on assessing sexual history taking and HIV counseling. Workshop participants scored one standard deviation higher on sexual history and HIV counseling items than nonparticipants. Our sexual history and HIV counseling curriculum was associated with students asking more thorough sexual histories and providing more HIV counseling.

Faculty and the observation of trainees' clinical skills: problems and opportunities

The clinical skills of medical interviewing, physical examination, and counseling remain vital to the effective care of patients, yet research continues to document serious deficiencies in clinical skills among students and residents. The most important method of evaluation is the direct observation of trainees performing these clinical skills. Standardized patients and other simulation technologies are important and reliable tools for teaching clinical skills and evaluating competence and will be incorporated in the near future as part of the United States Medical Licensing Examination. Standardized patients and simulation, however, cannot and should not replace the direct observation by faculty of trainees' clinical skills with actual patients. Faculty are in the best position to document improvement over time and to certify trainees have attained sophisticated levels of skill in medical interviewing, physical examination, and counseling. Unfortunately, current evidence suggests significant deficiencies in faculty direct observation evaluation skills. The author outlines the nature of the problems in clinical skills and their evaluation by faculty and ends with recommendations to improve the current state of faculty skills in evaluation.