Residency training in interviewing skills and the psychosocial domain of medical practice.
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Biomedical subjects
D E Kern
Publications and source records attributed to D E Kern.
A formula for estimating pretest probability: evaluation and clinical application.
Knowledge of the prevalence (or pretest probability) of a disease is necessary for the interpretation of the results of a diagnostic test in a specific population of patients. This paper evaluates a formula for estimating the prevalence of a disease in a population, based on the proportion of patients with abnormal test results in that population and the known sensitivity and specificity of the test. The authors tested the formula by using it to estimate the prevalence of myocardial infarction in 215 patients with chest pain admitted to a coronary care unit, based on results of initial total creatine kinase determinations. The estimated prevalence was 30%. The true prevalence of myocardial infarction, based on established diagnostic criteria, was 25% (95% confidence interval 19.2%-30.8%). To further evaluate the formula, a sensitivity analysis was performed. Errors in estimated prevalence were inversely related to test sensitivity and specificity, positively related to the magnitude of the differences between presumed and true test sensitivity and specificity, and complexly related to the true prevalence of disease. This formula permits the estimation of prevalence of a disease in a population without resorting to the use of a "gold standard" test, which is often invasive or impractical. Situations are presented where the formula could be used to evaluate and improve the utilization of laboratory tests.
Aged↗
An evaluation of residency training in interviewing skills and the psychosocial domain of medical practice.
Competent use of interviewing skills is important for the care of all patients but is especially critical, and frequently deficient, in meeting the needs of patients experiencing emotional distress. This study presents an evaluation of a curriculum in communication and psychosocial skills taught to first-year medical residents. A randomized experimental design compared trained and untrained residents' (n = 48) performances with a simulated patient presenting with atypical chest pain and psychosocial distress. Evaluation was based on analysis of videotapes, simulated patient report of residents' behaviors, and chart notation. Trained compared with untrained residents asked more open-ended questions and fewer leading questions, summarized main points more frequently, did more psychosocial counseling, and were rated as having better communication skills by the simulated patient. The use of more focused and psychosocially directed questions, and fewer leading and grab-bag questions, was associated with more accurate diagnoses and management recorded in the medical chart. However, no significant difference was found in the charting practices of trained versus untrained residents.
Chest Pain↗
Use of an outpatient medical record audit to achieve educational objectives: changes in residents' performances over six years.
OBJECTIVE: To evaluate the effectiveness of a process whereby a faculty-resident committee annually audits outpatient record keeping and preventive care practices and provides feedback to resident physicians. DESIGN: Pre- and postfeedback audits with interventions and observations repeated over six consecutive academic years. SETTING: The adult primary care practice of housestaff in a university-affiliated hospital. SUBJECTS: All 139 physicians in an internal medicine residency program from 1981-82 through 1986-87, of whom 37 were present for three consecutive years. INTERVENTION: Each year, residents were given individualized, detailed, typewritten feedback based on audits of their outpatient records. MEASUREMENTS AND MAIN RESULTS: Each resident physician had a minimum of four (mean 5.2) outpatient records per year audited against standards for record-keeping practices and the provision of preventive care. Overall performance scores for each resident audit improved from a mean of 39.7 +/- 12.3 (SD) in 1981-82 to a mean of 58.5 +/- 14.1 (SD) in 1986-87 (possible range 0 to 100, observed range 9.4 to 86.6). The overall performance scores of individual residents, who received two cycles of feedback, improved an average of 11.5 (95% confidence limits 7.6, 15.3), from a mean of 48.4 +/- 11.4 (SD) during their first year of residency to 59.8 +/- 13.9 (SD) during their third year. General (primary care) and traditional-track residents improved at similar rates, although mean performance scores were consistently higher for general than for traditional-track residents. Analysis of variance revealed that all changes and differences were statistically significant. CONCLUSIONS: An ongoing chart audit and feedback system can be associated with improvements both in the performance of individual residents and in the long-term performance of a residency program.
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