Using a multimedia tool to improve cardiac auscultation knowledge and skills

OBJECTIVE

Today's medical school graduates have significant deficits in physical examination skills. Medical educators have been searching for methods to effectively teach and maintain these skills in students. The objective of this study was to determine if an auscultation curriculum centered on a portable multimedia CD-ROM was effective in producing and maintaining significant gains in cardiac auscultatory skills.

DESIGN

Controlled cohort study.

PARTICIPANTS

All 168 third-year medical students at 1 medical school in an academic medical center.

INTERVENTIONS

Students were tested before and after exposure to 1 or more elements of the auscultation curriculum: teaching on ward/clinic rotations, CD-ROM comprehensive cases with follow-up seminars, and a CD-ROM 20-case miniseries. The primary outcome measures were student performance on a 10-item test of auscultation skill (listening and identifying heart sound characteristics) and a 30-item test of auscultation knowledge (factual questions about auscultation). A subset of students was tested for attenuation effects 9 or 12 months after the intervention.

RESULTS

Compared with the control group (1 month clinical rotation alone), students who were also exposed to the CD-ROM 20-case miniseries had significant improvements in auscultation skills scores (P < .05), but not knowledge. Additional months of clerkship, comprehensive CD-ROM cases, and follow-up seminars increased auscultation knowledge beyond the miniseries alone (P < .05), but did not further improve auscultation skills. Students' auscultation knowledge diminished one year after the intervention, but auscultation skills did not.

CONCLUSION

In addition to the standard curriculum of ward and conference teaching, portable multimedia tools may help improve quality of physical examination skills.

Teaching the one-minute preceptor. A randomized controlled trial

OBJECTIVE

The One-Minute Preceptor (OMP) model of faculty development is used widely to improve teaching, but its effect on teaching behavior has not been assessed. We aim to evaluate the effect of this intervention on residents' teaching skills.

DESIGN

Randomized controlled trial.

SETTING

Inpatient teaching services at both a tertiary care hospital and a Veterans Administration Medical Center affiliated with a University Medical Center.

PARTICIPANTS

Participants included 57 second- and third-year internal medicine residents that were randomized to the intervention group (n = 28) or to the control group (n = 29).

INTERVENTION

The intervention was a 1-hour session incorporating lecture, group discussion, and role-play.

MEASUREMENTS AND MAIN RESULTS

Primary outcome measures were resident self-report and learner ratings of resident performance of the OMP teaching behaviors. Residents assigned to the intervention group reported statistically significant changes in all behaviors (P <.05). Eighty-seven percent of residents rated the intervention as "useful or very useful" on a 1-5 point scale with a mean of 4.28. Student ratings of teacher performance showed improvements in all skills except "Teaching General Rules." Learners of the residents in the intervention group reported increased motivation to do outside reading when compared to learners of the control residents. Ratings of overall teaching effectiveness were not significantly different between the 2 groups.

CONCLUSIONS

The OMP model is a brief and easy-to-administer intervention that provides modest improvements in residents' teaching skills.

Perceived symptoms and health-related quality of life reported by uncomplicated hypertensive patients compared to normal controls

OBJECTIVES

This study compared the prevalence and intensity of symptoms and the health-related quality of life (HQL) of patients taking antihypertensive medications and patients without disease.

METHODS

This cross-sectional study used surveys mailed to patient's homes. All consecutive patients over age 30 years attending either a general medicine or hypertension clinic during 3 months were eligible (n = 437). Hypertension group (HTN-G) patients were diagnosed with primary hypertension, prescribed antihypertensive medications, and had no other symptomatic conditions or drug therapies. Control group (CNTL-G) patients were seen in the general medicine clinic and had no chronic symptomatic conditions or drug therapies. Measures included the Symptom Distress Checklist (SDC, list of 51 symptoms, frequency, and level of distress), the Medical Outcomes Study Short Form-36 (SF-36), medications, blood pressures, and other data obtained from medical records and patient self-report.

RESULTS

A total of 222 patients responded (46% CNTL-G, 55% HTN-G). HTN-G patients were somewhat older (59.0 +/- 11.2 vs 48.5 +/- 11.7 years, P = 0.001) and had a higher percent of minorities (24.8% vs 13.5%, P = 0.02), but otherwise similar. After adjusting for age and race differences, HTN-G patients reported significantly more symptoms (8.8 +/- 7.8 vs 4.7 +/- 4.8, P = 0.001) and related distress (32.2 +/- 4.2 vs 12.0 +/- 18.2, P = 0.001) as well as lower scores (reduced HQL) for most of the SF-36 domains. In general, hypertensive patients had more physical, but not mental symptoms than control patients.

CONCLUSIONS

Hypertensive patients receiving antihypertensive medications have more symptoms and lower HQL. Differences were detected by both a brief, general HQL instrument and a detailed, disease-specific instrument. Routine screening of treated hypertensive patients using a brief HQL questionnaire to detect physical symptoms may prove feasible and useful.

Learning styles and perceptions of the value of various learning modalities before and after a 2nd-year course in microbiology and infectious diseases

BACKGROUND

The authors' 4-week course in microbiology and infectious diseases consists of lectures, small-group sessions, interactive computer-assisted learning (CAL), and textbook readings.

PURPOSE

To determine how individual learning style influenced learners' value assessment of these teaching modalities.

METHODS

A Kolb Learning Style Inventory and questionnaire to assess enthusiasm for each teaching modality were administered before the course. At course end, a 2nd questionnaire assessed the perceived usefulness of each teaching modality.

RESULTS

Learners with a relative preference for experiential learning rather than abstraction initially favored small groups (R2 = .06, p = .004) and CAL (R2 = .06, p = .005). Similarly, learners with a preference for reflective observation rather than active experimentation favored lectures (R2 = .05, p = .01). However, at course end, Kolb learning style did not predict the value assessment of any modality.

CONCLUSIONS

Kolb learning style influenced the initial attractiveness but not the retrospective assessment of learning modalities; hence, quality and content superseded learning style as determinants of value after course completion.

Assessing medical students' awareness of and sensitivity to diverse health beliefs using a standardized patient station

PURPOSE

To assess students' performances on a health-beliefs communication OSCE station to determine whether there were differences in cultural competence based on the students' ethnic backgrounds.

METHOD

A total of 71 students completed a health-beliefs communication OSCE station in which they were required to address the health beliefs and cultural concerns of a standardized patient (SP) portraying an African American woman with diabetes. The SPs rated students' performances on a ten-item interview assessment checklist. Scores on the station were standardized within SPs to adjust for differences in their use of the rating scale. A factor analysis was performed to determine conceptual constructs on the interview assessment checklist. Subscale means were computed for each student. T-tests of these subscale scores were conducted to investigate gender and ethnic differences between subgroups of students. The underrepresented minority (URM) students (five African Americans and three Mexican Americans) were compared with all other students, and the white students were compared with all others. To assess the magnitudes of the differences between subgroups, effect sizes (ES(m)) were computed for means comparisons.

RESULTS

Factor analysis formed two factors: Disease Beliefs and Management, and Cultural Concerns. Two remaining items loaded on a third factor that had reliability too low to support further analysis. Meaningful differences were found in cultural sensitivity based on students' ethnic backgrounds. The URM students performed better than did all other students in addressing the patient's concerns about altering culturally-based dietary behaviors for diabetes self-care [URM students' mean standardized score (SD) = 0.42 (0.15); all others = -0.01 (0.67); ES(m) = 1.05]. White students performed better than did all other students in assessing the patient's concerns about using insulin to control her blood sugar levels [white students' mean standardized score (SD) = 0.13 (0.40); all others = -0.10 (0.64); ES(m) = 0.4].

CONCLUSION

Cultural competency deficits and differences were measurable using a health-beliefs communications station, and these differences were meaningful enough to warrant faculty discussion and research about how to ensure that students master this competency.

Is there a relationship between attending physicians' and residents' teaching skills and students' examination scores?

PURPOSE

Faculty development programs and faculty incentive systems have heightened the need to validate a connection between the quality of teaching and students' learning. This study was designed to determine the association between attending physicians' and residents' teacher ratings and their students' examination scores.

METHOD

From a database of 362 students, 138 faculty, and 107 residents in internal medicine, student-faculty (n = 476) and student-resident (n = 474) pairs were identified. All students were in their third year, rotating on inpatient general medicine and cardiology services, July 1994 through June 1996, at a single institution. The outcome measure for students' knowledge was the NBME Subject Examination in internal medicine. To control for students' baseline knowledge, the predictors were scores on the USMLE Step 1 and a sequential examination (a clinically-based pre- and post-clerkship examination). Teaching abilities of faculty and residents were rated by a global item on the post-clerkship evaluation. Faculty's ratings used only scores from prior to the study period; residents' ratings included those scores students gave during the study period.

RESULTS

Multivariate analyses showed faculty's teaching ratings were a small but significant predictor of the increase in students' knowledge. Residents' teaching ratings did not predict an increase in students' knowledge.

CONCLUSION

Attending faculty's clinical teaching ability has a positive and significant effect on medical students' learning.

The influence of task formats on the accuracy of medical students' self-assessments

PURPOSE

Accurate self-assessment is an essential skill for the self-directed learning activities and appropriate patient referral decisions of practicing physicians. However, many questions about the characteristics of self-assessment remain unanswered. One is whether self-assessment is a generalizable skill or dependent on the characteristics of the task. This study examines the self-assessment skills of medical students across two task formats: performance-based and cognitive-based.

METHOD

In 1997 and 1998, fourth-year medical students at the University of Michigan assessed their own performances on ten stations of a clinical examination. The examination used two formats: performance tasks (the examination or history taking of standardized patients) and cognitive tasks (interpreting vignettes or test results and then answering paper-and-pencil questions). Three measures of self-assessment accuracy were used: a bias index (average difference between the students' estimates of their performances and their actual scores), a deviation index (average absolute difference between estimate and actual score), and an actual score-estimate-of-performance correlation (the correlation between the estimate and actual scores).

RESULTS

The student bias and deviation indices were similar on the cognitive and the performance tasks. The correlations also indicated similarity between the two types of tasks.

CONCLUSION

The results indicate that the format of the task does not influence students' abilities to self-assess their performances, and that students' self-assessment abilities are consistent over a range of skills and tasks. The authors also emphasize the importance of sampling tasks while conducting self-assessment research.

Medical students' self-assessments and their allocations of learning time

PURPOSE

To investigate the impact of self-assessed diagnostic strengths and weaknesses on medical students' allocation of learning time (one indicator of self-directed learning) during a third-year internal medicine clerkship.

METHOD

In 1997-98, 107 students at the University of Michigan Medical School self-assessed their diagnostic skills in 14 clinical areas before and after the clerkship and reported the relative amounts of time spent learning about these topics during the clerkship.

RESULTS

Individual-level analyses indicated that, for the average student, self-assessed strengths and weaknesses did not correlate with allocation of educational time, but that time allocation was positively related to changes in self-assessed skill. Considerable variations in these relationships, however, suggest a need for closer study.

CONCLUSION

Although individual students evidenced different levels of self-directed learning, this study suggests overall that students at this level of training are neophytes in applying both information generated through self-assessment and principles of self-directed learning in their clinical education. Attempts to advance students beyond this level depend on many factors, including the extent to which the learning environment encourages or even permits self-directed learning, the progression and time frame through which students become self-directed practitioners, and the impact of educational interventions to promote this development.

The influence of treatment modality and ethnicity on attitudes in type 2 diabetes

OBJECTIVE

The study examines diabetes attitude differences by treatment modality (insulin vs. no insulin), race/ethnicity, and the interaction of these two variables for people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were collected with the Diabetes Care Profile (DCP), an instrument that assesses psychosocial factors related to diabetes. Participants (n = 672) were recruited in the metropolitan Detroit, Michigan, area from 1993 to 1996. A total of 68% of these participants were African-Americans with type 2 diabetes, and 32% were Caucasians with type 2 diabetes. Analyses of covariance were performed to examine the effects of race/ethnicity, treatment, and their interaction for each DCP scale.

RESULTS

The four patient categories (two ethnicities by two treatment modalities) differed by age, years with diabetes, education, and sex distribution. Treatment modality had a significant effect on 6 of the 16 DCP scales (Control, Social and Personal Factors, Positive Attitude, Negative Attitude, Self-Care Ability, and Exercise Barriers). Ethnicity was a significant effect for three scales (Control, Support, and Support Attitudes). The interaction of race/ethnicity and treatment modality was a significant effect for two related attitude scales (Positive Attitude and Negative Attitude).

CONCLUSIONS

The results suggest that attitudes toward diabetes are similar for African-American and Caucasian patients with type 2 diabetes. The results also suggest that treatment modality has a greater effect on attitudes than either race/ethnicity or the interaction effect. However, Caucasian patients using insulin differed from the other patient groups by having the least positive and the most negative attitudes regarding diabetes.

Evaluating the usefulness of computerized adaptive testing for medical in-course assessment

PURPOSE

This study investigated the feasibility of converting an existing computer-administered, in-course internal medicine test to an adaptive format.

METHOD

A 200-item internal medicine extended matching test was used for this research. Parameters were estimated with commercially available software with responses from 621 examinees. A specially developed simulation program was used to retrospectively estimate the efficiency of the computer-adaptive exam format.

RESULTS

It was found that the average test length could be shortened by almost half with measurement precision approximately equal to that of the full 200-item paper-and-pencil test. However, computer-adaptive testing with this item bank provided little advantage for examinees at the upper end of the ability continuum. An examination of classical item statistics and IRT item statistics suggested that adding more difficult items might extend the advantage to this group of examinees.

CONCLUSIONS

Medical item banks presently used for incourse assessment might be advantageously employed in adaptive testing. However, it is important to evaluate the match between the items and the measurement objective of the test before implementing this format.

The third version of the Diabetes Attitude Scale

OBJECTIVE

The objective of this study was to develop a third version of the Diabetes Attitude Scale (DAS-3) that is congruent with current scientific knowledge about diabetes, has improved subscale internal reliability scores, and is shorter than the earlier versions of this instrument.

RESEARCH DESIGN AND METHODS

The second DAS was revised and rewritten by a panel of diabetes experts, including patients, associated with the University of Michigan Diabetes Research and Training Center. The revised version of the instrument was sent to physicians, nurses, dietitians, and patients with diabetes. Completed and usable questionnaires were obtained from 384 patients with diabetes, 321 physicians, 540 nurses, and 569 dietitians. The total number of surveys used for these analyses was 1,814.

RESULTS

The study resulted in a revised DAS with 33 items and five discrete subscales. The subscales were attitudes toward the following: 1) need for special training to provide diabetes care, 2) seriousness of type 2 diabetes, 3) value of tight glucose control, 4) pyschosocial impact of diabetes, and 5) attitude toward patient autonomy. Overall, the subscale reliabilities of the DAS-3 were superior to the earlier versions of the scale.

CONCLUSIONS

The DAS-3 is a valid and reliable general measure of diabetes-related attitudes and is most suitable for comparisons across different groups of health care professionals and/or patients. The DAS-3 is also suitable for the evaluation of patient and/or professional education programs if those programs focus on the specific topic areas measured by the five DAS-3 subscales.

Training students in education of the hypertensive patient: enhanced performance after a simulated patient instructor (SPI)-based exercise

The process whereby a physician explains to the ill patient what has gone wrong and what can be done about it can be taught and evaluated by simulated patients (SPIs). This study was designed to determine whether a training experience in educating a diabetic SPI improves subsequent performance with a hypertensive SPI. Competence in educating a hypertensive SPI by students who had no prior training experience (n = 26) was compared to that of an experimental group (n = 20) that had a prior training session. Performance was assessed with a counseling skills scale and a case-specific content checklist (1 = poor to 5 = excellent). Students in the experimental group performed better than controls in both counseling skills (4.46 v 3.86, P < .01) and completeness of coverage of content (3.28 v 2.65, P < .01). Students in both groups focused more on clinical features and treatment than on laboratory testing and follow-up. The ability to counsel "patients" with hypertension can be enhanced by a prior learning experience with a diabetic SPI. Clinical application of knowledge about hypertension can be assessed by SPIs.

The reliability of the Diabetes Care Profile for African Americans

The Diabetes Care Profile (DCP) is an instrument used to assess social and psychological factors related to diabetes and its treatment. The reliability of the DCP was established in populations consisting primarily of Caucasians with type 2 diabetes. This study tests whether the DCP is a reliable instrument for African Americans with type 2 diabetes. Both African American (n = 511) and Caucasian (n = 235) patients with type 2 diabetes were recruited at six sites located in the metropolitan Detroit area. Scale reliability was calculated by Cronbach's coefficient alpha. The scale reliabilities ranged from .70 to .97 for African Americans. These reliabilities were similar to those of Caucasians, whose scale reliabilities ranged from .68 to .96. The Feldt test was used to determine differences between the reliabilities of the two patient populations. No significant differences were found. The DCP is a reliable survey instrument for African American and Caucasian patients with type 2 diabetes.

A predictive model of student satisfaction with the medical school learning environment

PURPOSE

To examine differences in attitudes toward the medical school learning environment among student subgroups based on gender and race-ethnicity, to identify the most influential predictors of student satisfaction with the learning environment, and to create a model of student satisfaction with the learning environment.

METHOD

Three years of survey data (1992-93 to 1994-95) from first-year students at the University of Michigan Medical School were combined. The total sample consisted of 430 respondents, broken into two sets of subgroups: women (n = 171) and men (n = 259), and whites (n = 239) and underrepresented minorities (n = 74). Asian students were removed from analyses when comparisons were made by race-ethnicity, but were included in the analyses for all students and those comparing men and women. Student's t-tests were used to identify differences between gender and racial-ethnic groups in mean responses to seven survey items, and effect sizes were used to characterize the magnitudes and practical significances of the differences. Forward stepwise regression was conducted to determine the best predictive models for each student subgroup and for the total sample; the subgroup models were compared with each other as well as with the total-sample model.

RESULTS

Cross-validation of the gender and race-ethnicity models showed that the men's satisfaction and the women's satisfaction were predicted equally well using either subgroup's model, and that the white students' satisfaction and the underrepresented-minority students' satisfaction were predicted equally well using either subgroup's model. Furthermore, the total-sample model, employing a subset of five predictors, was similar in its predictive power to the subgroup models.

CONCLUSION

The study's findings suggest that curriculum structure (timely feedback and the promotion of critical thinking) and students' perceptions of the priority faculty place on students' education are prominent predictors of student satisfaction (across all subgroups) with the learning environment. In contrast, students' perceptions of the learning environment as a comfortable place for all gender and racial-ethnic groups, although less prominent predictors of satisfaction, will discriminate among the subgroups.

Implications of cognitive research for ambulatory care education

Research in cognitive psychology has led to changes in how educators conceptualize thinking and approach improving students' thinking processes. As medical education moves into ambulatory care settings, there is an opportunity for educators to consider the implications of cognition theories for the ambulatory case curriculum. In this paper, the author briefly explains four major concepts of cognitive theory-the importance of context; students' need for transferable knowledge; the importance of balancing depth and breadth of knowledge; and the role of prior knowledge in problem solving- and discusses the possible implications of each concept for ambulatory care educations.

Teaching skills for accessing and interpreting information from systematic reviews/meta-analyses, practice guidelines, and the Internet

Skills and practice related to accessing and interpreting clinical information from systematic reviews/meta-analyses, practice guidelines, and the Internet have been integrated into a new senior year elective designed to teach medical students how to critically appraise information from a variety of sources and evaluate it's applicability to patient care. Small groups of senior medical students under the direction of a multidisciplinary team (behavioral scientist, information specialist, physician) facilitate discussions of clinical articles using checklists designed to evaluate their quality. The central feature of the course is a demonstration of the Cochrane Database of Systematic Reviews (CDSR), an electronic journal distributed by BMJ Publishing, and the requirement that students conduct a literature review on a topic of their choice and present an oral and written summary in the form of a "draft" meta-analysis. Students are provided with strategies to "surf" the Internet/WWW for information, e.g., practice guidelines/treatment protocols, descriptions of on-going clinical trials. A total of 52 students have participated to date. Students have selected project topics across a wide range of medical disciplines, including internal medicine, family practice, OB/GYN, pediatrics, surgery, neurology, emergency medicine, and psychiatry. The course is one of the most favorably evaluated of all senior electives and rated more favorably than the overall mean ratings for all electives combined on 8 of 9 scales, including "Quality of course overall" (4.39 vs. 3.92 on 5-point scale).

The use of trained patient educators with rheumatoid arthritis to teach medical students

OBJECTIVE

To assess whether patients with rheumatoid arthritis (RA) trained as educators can enhance the integration of clinical and basic science education among second-year medical students during their rheumatology sequence.

METHODS

Twenty patients with RA and strong communication skills were extensively trained to teach students how to perform the whole-body joint examination. Each arthritis educator taught three 2-hour small group sessions and participated in a concluding 2-hour panel discussion with the entire class. Changes in student knowledge and attitudes were assessed in a pre-post evaluation design.

RESULTS

There were statistically and educationally significant gains in knowledge, confidence, and attitudes related to psychosocial aspects of arthritis in each of the 2 years the program was implemented. One-year followup data indicated substantial retention of these gains.

CONCLUSIONS

Patients trained in arthritis education can effectively teach fundamental musculoskeletal examination skills and encourage the development of sensitivity to the impact of chronic arthritis on the daily life of other patients.

Measuring attending physician performance in a general medicine outpatient clinic

OBJECTIVE

To determine which aspects of outpatient attending physician performance (e.g., clinical ability, teaching ability, interpersonal conduct) were measurable and separable by resident report.

DESIGN

Self-administered evaluation form.

SETTING

University internal medicine resident continuity clinic.

PARTICIPANTS

All residents with their continuity clinic at the university hospital evaluated the two attendings who staffed their clinic for the academic years of 1990-1991, 1991-1992, and 1992-1993 (average of 85 total residents per year). The overall response rate was 74%.

ANALYSIS

Exploratory analyses were conducted on a preliminary evaluation form in the first two years of the study (236 evaluations of 20 different clinic attendings) and confirmatory analyses using factor analysis and generalizability analysis were performed on the third year's data (142 evaluations of 15 different clinic attendings). Analysis of variance was used to evaluate factors associated with evaluation scores.

RESULTS

Analyses demonstrated that the residents did not distinguish between the attendings' clinical and teaching abilities, resulting in a single four-item scale that was named the Clinical/Teaching Excellence Scale, measured on a five-point scale from poor to outstanding (Cronbach's alpha = 0.92). A large amount of the variance for this scale score was associated with attending identity (adjusted R2 = 46%). However, two alternative approaches to evaluating the performance of the attending (preference for him or her to the "average" attending and perceived impact of the attending on residents' clinical skills) did not provide useful information independent of the Clinical/Teaching Excellence Scale. The ratings of three separate conduct scales [availability in clinic (Availability Scale), treating residents and patients with respect (Respect Scale), and time efficiency in staffing cases (Slow Staffing Scale)] were separable from each other and from the rating of clinical/teaching excellence. For the Clinical/Teaching Excellent Scale, as few as four evaluations produced good interrater reliability and eight evaluations produced excellent reliability (reliability coefficients were 0.70 and 0.84, respectively).

CONCLUSIONS

Although this evaluation instrument for measuring clinic attending performance must be considered preliminary, this study suggests that relatively few attending evaluations are required to reliably profile an individual attending's performance, that attending identity is associated with a large amount of the scale score variation, and that special issues of attending performance more relevant to the outpatient setting than the inpatient setting (availability in clinic and sensitivity to time efficiency) should be considered when evaluating clinic attending performance.

The development and evaluation of new versions of the written examination for the American Heart Association Advanced Cardiac Life Support provider course

STUDY OBJECTIVE

To create new versions of the written, multiple-choice examination used in the American Heart Association (AHA) Advanced Cardiac Life Support course, evaluate their reliability and difficulty, and then design revised versions with improved reliability and of standardized difficulty.

DESIGN

Psychometric evaluation of new versions of the AHA Advanced Cardiac Life Support test and revisions.

SETTING

AHA Advanced Cardiac Life Support courses.

PARTICIPANTS

Candidates for completion of AHA Advanced Cardiac Life Support provider courses in five states.

INTERVENTION

The course content was divided into 11 content areas that were weighted for importance and appropriateness for testing in a multiple-choice format. The weights were used to construct a blueprint for a 50-question, multiple-choice examination. Five versions of the examination were then constructed based on the content blueprint, drawing from new questions and expert revision of previously written questions. Reliability and difficulty were assessed using 915 administrations at five different sites nationwide. The initial test versions differed in their degree of difficulty, which was not explained by demographic factors. The results were used to revise three of the versions to improve reliability and equalize difficulty of the versions.

MEASUREMENTS AND MAIN RESULTS

The final five versions have estimated reliability ranging from Cronbach's alpha of .62 to .86. Mean scores ranged from 87.4% to 89.1%.

CONCLUSION

After field testing and revision, five examinations with acceptable reliability and roughly equal difficulty were constructed. The new examinations test the participants' knowledge of important aspects of resuscitation science and practice based on a blueprint of the course content.

Assessing the consistency and educational benefits of students' clinical experiences during an ambulatory care internal medicine rotation

BACKGROUND

Although ambulatory care settings are being used increasingly in undergraduate clinical education, variability in the depth and breadth of students' contacts with basic medical problems may compromise the educational benefits of this teaching modality. The present study examines the nature of such variation and the educational effectiveness of ambulatory care education.

METHOD

During the one-month ambulatory care component of the third-year internal medicine rotation at the University of Michigan Medical School, 43 students in 1989-90 and 1990-91 recorded the patient problems they saw at a hospital and satellite clinics. In addition, the students' diagnostic-recognition abilities were assessed before and after the component. The extents of the students' experiences in various categories of patient problems were quantified and correlated with their diagnostic abilities in relevant content areas.

RESULTS

The students saw many categories of problems but few instances in any given category. There were numerous and potentially worrisome gaps in their exposure to several typical ambulatory care problems. Although the students showed significant increases in diagnostic-recognition abilities, these increases were not correlated with the students' levels of experience in any of the relevant problem categories.

CONCLUSION

The variability and potentially worrisome gaps in the students' experiences in the ambulatory care settings studied are probably representative of students' experiences in such settings, and should be considered in the implementation and evaluation of educational experiences in ambulatory care.

Medical student use of history and physical information in diagnostic reasoning

Clinical data gathering is central to clinical competence. Although research has demonstrated the value to experienced clinicians of information obtained from the history, little is known of how medical students use this information. In the present study, two case simulations (in rheumatoid arthritis and systemic lupus erythematosis) were developed to assess medical student information gathering and utilization. The results indicate that most of the students were already considering the correct diagnosis as a possibility after the presenting complaint and patient description. However, the medical history exerted the strongest influence on transforming the correct diagnosis from just another diagnostic possibility into the favored diagnostic candidate. Students who failed to list the correct diagnosis in the differential diagnosis after obtaining the history were significantly less likely to reach the correct diagnosis at the end of the case. These results confirm the critical importance of the history in medical problem solving.

Information gathering and integration as sources of error in diagnostic decision making

This research examined the relative importance of information gathering versus information utilization in accounting for errors in diagnostic decision making. Two experiments compared physicians' performances under two conditions: one in which they gathered a limited amount of diagnostic information and then integrated it before making a decision, and the other in which they were given all the diagnostic information and needed only to integrate it. The physicians: 1) frequently failed to select normatively optimal information in both experimental conditions; 2) were more confident about the correctness of their information selection when their task was limited to information integration than when it also included information gathering; and 3) made diagnoses in substantial agreement with those indicated by applying normative procedures to the same data. Physicians appear to have difficulties recognizing the diagnosticity of information, which often results in decisions that are pseudodiagnostic or based on diagnostically worthless information.

Physician information seeking: improving relevance through research

Health sciences libraries have considerable potential as resources for both formal continuing professional education, as well as the informal continuing education that results from the professional's efforts to solve problems in daily practice. While there is a growing interest in making the resources of health sciences libraries more accessible to practitioners on a routine, day-to-day basis, there also needs to be more awareness of how, when, where, and why professionals look for information in the context of practical problems. This paper reviews recent research that identifies the context in which physicians seek information and advice from external sources, the information sources that physicians access, and the factors that influence which particular sources are sought. The results indicate that physicians vary in their information needs, preferences, motivations, and strategies for seeking information. This diversity suggests that health sciences libraries, in their efforts to be more accessible, should consider "market research" to determine the needs, preferences, and use patterns of the library's targeted users. Libraries may also benefit from exploring alternative methods of improving access to their resources.

The influence of general and case-related experience on primary care treatment decision making

In an effort to examine how general vs case-related clinical experience influenced physicians' treatment decisions, four clinical case vignettes (rheumatoid arthritis, fever of undetermined origin, exercise-induced asthma, and cor pulmonale) were presented to 387 primary care physicians. For each case, physicians indicated (1) their willingness to proceed with treatment without seeking additional information, (2) their preferences for sources of supplementary information, and (3) their preferences for continued care responsibility. The results indicated that the nature of the particular vignette had a major impact on how physicians made treatment decisions. Also, having greater case-related experience and being younger led to greater willingness to proceed with treatment and preferences for continued care responsibility. Preferences for information sources were largely independent of either form of experience. Treatment decision making appears to be quite dependent on experience with similar problems and being up-to-date on current treatment procedures.

Information-seeking strategies and differences among primary care physicians

Differences in the sources of information that physicians utilize in their practice have several implications for the quality of care delivered and the dissemination of medical information. In order to examine the extent of differences in information preferences in primary care settings, 98 general internal medicine physicians and 73 family physicians were asked to indicate which of six alternative information sources they relied on most when faced with difficult medical problems. The alternatives were: journals, textbooks, informal consultations with colleagues, consultations with community specialists, consultations with outside specialists, and transfer of the patient to another physician. The results indicated that primary care internists have a greater preference for consulting the medical literature, while family physicians more often rely on colleagues and specialists as sources of information. These differences suggest that the focus of information dissemination through journals or textbooks may be more effective for internists, while colleagues or "educationally influential" physicians in the community may be more effective vehicles for information dissemination to family physicians.

Differential diagnosis and the competing-hypotheses heuristic. A practical approach to judgment under uncertainty and Bayesian probability

Evaluating the same diagnostic information across the plausible competing diagnoses is a practical strategy (ie, heuristic) to guide decision making in the face of uncertainty. The prevalence of use of this competing-hypotheses heuristic by 89 first-year house officers was examined in three simulated patient cases. Results indicated that only a minority (24%) of the house officers selected optimal diagnostic information consistent with this Bayesian heuristic across all three cases. Almost all (97%) of the house officers selecting optimal diagnostic information were able to identify the most probable diagnosis specified by Bayes' theorem, while only a chance number (53%) of house officers selecting nonoptimal information were able to identify the most probable diagnosis. The competing-hypotheses heuristic is discussed within the context of diagnostic problem-solving models derived from the literature on medical decision making and clinicopathological conference case records. It is suggested that the heuristic, which does not necessitate any mathematical calculations, may be useful as a complement to clinical judgment.