Search

Recent changes to the patient note (PN) format of the United States Medical Licensing Examination have challenged medical schools to improve the instruction and assessment of students taking the Step-2 clinical skills examination. The purpose of this study was to gather validity evidence regarding response process and internal structure, focusing on inter-rater reliability and generalizability, to determine whether a locally-developed PN scoring rubric and scoring guidelines could yield reproducible PN scores. A randomly selected subsample of historical data (post-encounter PN from 55 of 177 medical students) was rescored by six trained faculty raters in November-December 2014. Inter-rater reliability (% exact agreement and kappa) was calculated for five standardized patient cases administered in a local graduation competency examination. Generalizability studies were conducted to examine the overall reliability. Qualitative data were collected through surveys and a rater-debriefing meeting. The overall inter-rater reliability (weighted kappa) was 0.79 (Documentation = 0.63, Differential Diagnosis = 0.90, Justification = 0.48, and Workup = 0.54). The majority of score variance was due to case specificity (13%) and case-task specificity (31%), indicating differences in student performance by case and by case-task interactions. Variance associated with raters and its interactions were modest (<5%). Raters felt that justification was the most difficult task to score and that having case and level-specific scoring guidelines during training was most helpful for calibration. The overall inter-rater reliability indicates high level of confidence in the consistency of note scores. Designs for scoring notes may optimize reliability by balancing the number of raters and cases.

Objective structured clinical examinations (OSCEs) are used worldwide for summative examinations but often lack acceptable reliability. Research has shown that reliability of scores increases if OSCE checklists for medical students include only clinically relevant items. Also, checklists are often missing evidence-based items that high-achieving learners are more likely to use. The purpose of this study was to determine if limiting checklist items to clinically discriminating items and/or adding missing evidence-based items improved score reliability in an Internal Medicine residency OSCE. Six internists reviewed the traditional checklists of four OSCE stations classifying items as clinically discriminating or non-discriminating. Two independent reviewers augmented checklists with missing evidence-based items. We used generalizability theory to calculate overall reliability of faculty observer checklist scores from 45 first and second-year residents and predict how many 10-item stations would be required to reach a Phi coefficient of 0.8. Removing clinically non-discriminating items from the traditional checklist did not affect the number of stations (15) required to reach a Phi of 0.8 with 10 items. Focusing the checklist on only evidence-based clinically discriminating items increased test score reliability, needing 11 stations instead of 15 to reach 0.8; adding missing evidence-based clinically discriminating items to the traditional checklist modestly improved reliability (needing 14 instead of 15 stations). Checklists composed of evidence-based clinically discriminating items improved the reliability of checklist scores and reduced the number of stations needed for acceptable reliability. Educators should give preference to evidence-based items over non-evidence-based items when developing OSCE checklists.

Purpose: There is a paucity of evaluation forms specifically developed and validated for outpatient settings. The purpose of this study was to develop and validate an instrument specifically for evaluating outpatient teaching, to provide reliable and valid ratings for individual and group feedback to faculty, and to identify outstanding teachers in that setting. Method: By literature reviews and pilot studies at the Faculties of Health Sciences, McMaster University (Canada) and Aga Khan University (AKU-Pakistan), a 15-item instrument, Student Evaluation of Teaching in Outpatient Clinics (SETOC), was created with five subscales: "Establishing Learning-Milieu, Clinical-Teaching, General-Teaching, Clinical-Competence, and Global-Rating." Seven-point Likert-type rating scales were used. Students also nominated three "best" outpatient teachers. Participants: 87 faculty members (79%) rated by all 224 third to fifth-year students (clerks) at outpatient departments of the AKU hospital over a one-year period. Analyses: Repeated measures generalizability studies, correlations, concurrent validity of SETOC scores with best teacher nominations. Results: Inter-rater G-coefficient and internal consistency of SETOC student ratings were 0.92 and 0.98. Average inter-item and inter-subscale correlations were 0.79 and 0.86. Comparing SETOC scores against "Best Teacher" nominations, sensitivity, specificity, positive and negative predictive values were greater than 0.84.Student ratings ranged from unsatisfactory (fourteen instructors) to outstanding (four instructors). Mean-scores for Learning-Milieu, Clinical-Teaching and General-Teaching were lower than those for Clinical-Competence and Global-Rating (p=0.000 for all). Conclusions: The SETOC elicited reliable and valid student ratings that can provide specific feedback to individual faculty with weak or outstanding teaching skills, and identify overall group shortcomings for faculty development.

The diagnostic discourse of medical students and physicians in thinking-aloud protocols on paper cases was analyzed for evidence of semantic structure. Results show that structural semantics can be used to distinguish various levels of mental processing among novices as well as between novices and professionals. (MSE)

Background: SNAPPS is a learner-centered approach to case presentations that was shown, in American studies, to facilitate the expression of clinical reasoning and uncertainties in the outpatient setting. Aim: To evaluate the SNAPPS technique in an Asian setting. Methods: We conducted a quasi-experimental trial comparing the SNAPPS technique to the usual-and-customary method of case presentations for fifth-year medical students in an ambulatory internal medicine clerkship rotation at Khon Kaen University, Thailand. We created four experimental groups to test main and maturation effects. We measured 12 outcomes at the end of the rotations: total, summary, and discussion presentation times, number of basic clinical findings, summary thoroughness, number of diagnoses in the differential, number of justified diagnoses, number of basic attributes supporting the differential, number of student-initiated questions or discussions about uncertainties, diagnosis, management, and reading selections. Results: SNAPPS users (90 case presentations), compared with the usual group (93 presentations), had more diagnoses in their differentials (1.81 vs. 1.42), more basic attributes to support the differential (2.39 vs. 1.22), more expression of uncertainties (6.67% vs. 1.08%), and more student-initiated reading selections (6.67% vs. 0%). Presentation times did not differ between groups (12 vs. 11.2 min). There were no maturation effects detected. Conclusions: The use of the SNAPPS technique among Thai medical students during their internal medicine ambulatory care clerkship rotation did facilitate the expression of their clinical reasoning and uncertainties. More intense student-preceptor training is needed to better foster the expression of uncertainties. [ABSTRACT FROM AUTHOR]

Objective structured clinical examinations (OSCEs) are used worldwide for summative examinations but often lack acceptable reliability. Research has shown that reliability of scores increases if OSCE checklists for medical students include only clinically relevant items. Also, checklists are often missing evidence-based items that high-achieving learners are more likely to use. The purpose of this study was to determine if limiting checklist items to clinically discriminating items and/or adding missing evidence-based items improved score reliability in an Internal Medicine residency OSCE. Six internists reviewed the traditional checklists of four OSCE stations classifying items as clinically discriminating or non-discriminating. Two independent reviewers augmented checklists with missing evidence-based items. We used generalizability theory to calculate overall reliability of faculty observer checklist scores from 45 first and second-year residents and predict how many 10-item stations would be required to reach a Phi coefficient of 0.8. Removing clinically non-discriminating items from the traditional checklist did not affect the number of stations (15) required to reach a Phi of 0.8 with 10 items. Focusing the checklist on only evidence-based clinically discriminating items increased test score reliability, needing 11 stations instead of 15 to reach 0.8; adding missing evidence-based clinically discriminating items to the traditional checklist modestly improved reliability (needing 14 instead of 15 stations). Checklists composed of evidence-based clinically discriminating items improved the reliability of checklist scores and reduced the number of stations needed for acceptable reliability. Educators should give preference to evidence-based items over non-evidence-based items when developing OSCE checklists. [ABSTRACT FROM AUTHOR]

Introduction: The physical examination is an essential clinical competence for all physicians. Most medical schools have students who learn the physical examination maneuvers using a head-to-toe approach. However, this promotes a rote approach to the physical exam, and it is not uncommon for students later on to fail to appreciate the meaning of abnormal findings and their contribution to the diagnostic reasoning process. The purpose of the project was to develop a model teaching session for the hypothesis-driven physical examination (HDPE) approach in which students could practice the physical examination in the context of diagnostic reasoning. Methods: We used an action research methodology to create this HDPE model by developing a teaching session, implementing it over 100 times with approximately 700 students, conducting internal reflection and external evaluations, and making adjustments as needed. Results: A model nine-step HDPE teaching session was developed, including: (1) orientation, (2) anticipation, (3) preparation, (4) role play, (5) discussion-1, (6) answers, (7) discussion-2, (8) demonstration and (9) reflection. Discussions and conclusions: A structured model HDPE teaching session and tutor guide were developed into a workable instructional intervention. Faculty members are invited to teach the physical examination using this model. [ABSTRACT FROM AUTHOR]

Medical Education 2010: 44: 775–785 Objectives This study aimed to test the extent to which the use of medicalese (i.e. formal medical terminology and semantic qualifiers) alters the test performance of medical graduates; to tease apart the extent to which any observed differences are driven by language difficulties versus differences in medical knowledge; and to assess the impact of varying the language used to present clinical features on the ability of the test to consistently discriminate between candidates. Methods Six clinical cases were manipulated in the context of pilot items on the Canadian national qualifying examination. Features indicative of two diagnoses were presented uniformly in lay terms, medical terminology and semantic qualifiers, respectively, and in mixed combinations (e.g. features of one diagnosis were presented using lay terminology and features of the other using medicalese). The rate at which the indicated diagnoses were named was considered as a function of language used, site of training, birthplace and medical knowledge (as measured by overall performance on the examination). Results In the mixed conditions, Canadian medical graduates were not influenced by the language used to present the cases, whereas international medical graduates (IMGs) were more likely to favour the diagnosis associated with medical terminology relative to that associated with lay terms. This was true regardless of whether the entire sample or only North American-born candidates were considered. Within the IMG cohort, high performers were not influenced by the language manipulation, whereas low performers were. Uniform use of lay terminology resulted in the highest test reliability compared with the other experimental conditions. Conclusions The results indicate that the influence of medical terminology is driven more by substandard medical knowledge than by the language issues that challenge some candidates. Implications for both the assessment and education of medical professionals are discussed. [ABSTRACT FROM AUTHOR]

Objectives Case specificity implies that success on any case is specific to that case. In examining the sources of error variance in performance on case-based examinations, how much error variance results from differences between cases compared with differences between items within cases? What is the optimal number of cases and questions within cases to maximise test reliability given some fixed period of examination time? Methods G and D generalisability studies were conducted to identify variance components and reliability for each examination analysed, and to optimise the reliability of the given test composition (1, 1.5, 2, 3, 4 and 5 questions per case), using data from 3 key features examinations of the Medical Council of Canada ( n = 6342 graduating medical students), each of which consisted of about 35 written cases followed by 1–4 questions regarding specific key elements of data gathering, diagnosis and/or management. Results The smallest variance component was due to subjects; the variance due to subject–item interaction was over 5 times the interaction with cases (on average, 0.1106 compared with 0.0195). Relatively little variance was due to differences between cases; about 80% of the error variance was due to variability in performance among items within cases. The D study showed that reliability varied between 0.541 and 0.579, was least with 1 item per case and highest at 2 and 3 items per case. Conclusions The main source of error variance was items within cases, not cases, and the optimal strategy in terms of enhancing reliability would use cases with 2–3 items per case. [ABSTRACT FROM AUTHOR]

Background: Third-year medical students (MS3) were given clinical encounter cards (CECs) to stimulate feedback during their surgery clerkship. This study analyzes the feedback given on their clinical performance using CECs. Methods: Two hundred one students enrolled in the 12-week surgery clerkship were given CECs. Each card contained the chief focus of the encounter, which was rated on a six-point Likert scale. The CECs were analyzed to determine if they provided reliable formative information, identified marginal performances, and identified differences between raters, settings, rotations, and aspects of clinical performance evaluated. Results: Seven thousand three hundred eight CECs were submitted from 201 students. The CECs were completed most often (65%) in the inpatient setting. Technical skills were evaluated on 49% of CECs, history/physical examinations on 40%, and case presentations on 30%. There were comments written on half of the CECs and 89% of these were strictly positive. Women (52.8%) and faculty (63.3%) were more likely to provide written comments. The students were most likely to seek feedback from the interns and faculty who gave significantly higher ratings. The Cronbach-alpha reliability coefficient was 0.69, based on 12 raters per student. There was a significant positive correlation (P < 0.05) between the CEC composite rating and the clinical performance rating (r = 0.356), NBME score (r = 0.258), and the final grade (r = 0.250). Conclusions: The implementation of CECs in a surgery clerkship provided a large quantity of positive feedback. The quality was limited because there were minimal recommendations for improvement and they were a poor predictor of overall clinical performance. [Copyright &y& Elsevier]