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J J Rethans

Publications and source records attributed to J J Rethans.

33 records · Page 2Linked to original sources
PubMed1996

Methods for quality assessment in general practice.

BACKGROUND AND OBJECTIVES: There is now a wide variety of methods available to general practitioners who want to engage in quality assessment, quality assurance, or quality improvement activities in their practices. These methods require some kind of performance review, or at least the collection of some performance-related data. As in traditional research, the choice of methods depends on what research questions one wants to address. This paper elaborates on some key concepts related to the choice of methods, making a distinction between whether any method actually covers performance (what a doctor does in daily practice) or competence (what a doctor is capable of doing) as well as a distinction between whether a method is direct (patient-doctor contact is observable) or is indirect. METHOD: An overview frame will be presented of the methods most commonly used for data collection within quality assessment. These methods are discussed on their validity, reliability, feasibility and acceptability. Direct methods aimed at recording performance are assumed to hold the highest validity, but practical, economic and logistic factors may favour less ambitious methods for audit or quality improvement activities. CONCLUSIONS: One crucial element in all methods is creating a set of empirical data, as a basis for comparisons, reflection, dialogue and discussions among colleagues.

Data Collection↗
PubMed1996

Performance-based assessment in continuing medical education for general practitioners: construct validity.

The use of performance-based assessment has been extended to postgraduate education and practising doctors, despite criticism of validity. While differences in expertise at this level are easily reflected in scores on a written test, these differences are relatively small on performance-based tests. However, scores on written tests and performance-based tests of clinical competence generally show moderate correlations. A study was designed to evaluate construct validity of a performance-based test for technical clinical skills in continuing medical education for general practitioners, and to explore the correlation between performance and knowledge of specific skills. A 1-day skills training was given to 71 general practitioners, covering four different technical clinical skills. The effect of the training on performance was measured with a performance-based test using a randomized controlled trial design, while the effect on knowledge was measured with a written test administered 1 month before and directly after the training. A training effect could be shown by the performance-based test for all four clinical skills. The written test also demonstrated a training effect for all but one skill. However, correlations between scores on the written test and on the performance-based test were low for all skills. It is concluded that construct validity of a performance-based test for technical clinical skills of general practitioners was demonstrated, while the knowledge test score was shown to be a poor predictor of competence for specific technical skills.

Adult↗
PubMed1995

[Standardized patients in general practice--a new method for quality assurance in Noway].

Standardized patients were sent to general practitioners who use the patient list system in Trondheim in order to register daily clinical practice without the patient being unmasked. The authors explain what a standardized patient is, how they are taught to present a disease, and how they report on the consultation in a valid and reliable way. They also describe how the standardized patients were introduced into the doctors' patient list system. The doctors were informed about the project in advance. Twenty-three doctors were visited twice and one doctor was visited once by a standardized patient. At two of the visits the patient was unmasked. The conclusion is that the use of standardized patients is a valid, reliable and practical method for quality assurance in general practice in Norway.

Family Practice↗
PubMed1995

Assessment of competence in technical clinical skills of general practitioners.

Technical clinical procedures constitute an important part of the work of general practitioners. Assessment of competence in the relevant skills is important from the perspective of quality assurance. In this study, the psychometric characteristics of three different methods for assessment of competence in technical clinical skills in general practice were evaluated. A performance-based test (8 stations), a written knowledge test of skills (125 items) and a self-assessment questionnaire (41 items) on technical clinical skills were administered to 49 GPs and 47 trainees in general practice. The mean scores on the performance-based test and the written knowledge test of skills showed no substantial differences between GPs and trainees, whereas the GPs scored higher on the self-assessment questionnaire. While the correlation of the score on the knowledge test of skills with the score on the performance-based test was moderately high, the score on the self-assessment questionnaire showed a rather low correlation with the performance-based test. Although performance-based testing is obviously the best method to assess proficiency in hands-on skills, a written test can serve as a reasonable alternative, particularly for screening and research purposes.

Clinical Competence↗
PubMed1994

To what extent do clinical notes by general practitioners reflect actual medical performance? A study using simulated patients.

BACKGROUND: Review of clinical notes is used extensively as an indirect method of assessing doctors' performance. However, to be acceptable it must be valid. AIM: This study set out to examine the extent to which clinical notes in medical records of general practice consultations reflected doctors' actual performance during consultations. METHOD: Thirty nine general practitioners in the Netherlands were consulted by four simulated patients who were indistinguishable from real patients and who reported on the consultations. The complaints presented by the simulated patients were tension headache, acute diarrhoea and pain in the shoulder, and one presented for a check up for non-insulin dependent diabetes. Later, the doctors forwarded their medical records of these patients to the researchers. Content of consultations was measured against accepted standards for general practice and then compared with content of clinical notes. An index, or content score, was calculated as the measure of agreement between actions which had actually been recorded and actions which could have been recorded in the clinical notes. A high content score reflected a consultation which had been recorded well in the medical record. The correlation between number of actions across the four complaints recorded in the clinical notes and number of actions taken during the consultations was also calculated. RESULTS: The mean content score (interquartile range) for the four types of complaint was 0.32 (0.27-0.37), indicating that of all actions undertaken, only 32% had been recorded. However, mean content scores for the categories 'medication and therapy' and 'laboratory examination' were much higher than for the categories 'history' and 'guidance and advice' (0.68 and 0.64, respectively versus 0.29 and 0.22, respectively). The correlation between number of actions across the four complaints recorded in the clinical notes and number of actions taken during the consultations was 0.54 (P < 0.05). CONCLUSION: The use of clinical notes to audit doctors' performance in Dutch general practice is invalid. However, the use of clinical notes to rank doctors according to those who perform many or a few actions in a consultation may be justified.

Clinical Competence↗
PubMed1991

Does competence of general practitioners predict their performance? Comparison between examination setting and actual practice.

OBJECTIVE: To study the differences and the relation between what a doctor actually does in daily practice (performance) and what he or she is capable of doing (competence) by using national standards for general practice. DESIGN: General practitioners were consulted by four standardised (simulated) patients portraying four different cases during normal surgery hours. Later the doctors participated in a controlled practice test, for which they were asked to perform to the best of their ability. In the test they saw exactly the same standardised cases but in different patients. The patients reported on the consultations. SETTING: Province of Limburg, the Netherlands. SUBJECTS: 442 general practitioners invited by a letter. 137 (31%) agreed to participate, of whom 36 were selected and visited. MAIN OUTCOME MEASURES: Number of actions taken during the consultations across complaints and for each category of complaint: the competence and performance total scores. Combination of scores with duration of consultations (efficiency-time score). Correlation between scores in the competence and performance part. RESULTS: Mean (SD) total score across complaints for competence was 49% higher than in the performance test (81.8 (11) compared with 54.7 (10.1), p less than 0.0001). The Pearson correlation across complaints between the competence total score and the performance total score of the participating physicians was -0.04 (not significant). When efficiency and consultation time of the consultations were taken into account, the correlation was 0.45 (p less than 0.01). CONCLUSIONS: Assessment of competence under examination circumstances can have predictive value for performance in actual practice only when factors such as efficiency and consultation time are taken into account. Below standard performance of physicians does not necessarily reflect a lack of competence. Performance and competence should be considered as distinct constructs.

Clinical Competence↗
PubMed1991

A method for introducing standardized (simulated) patients into general practice consultations.

A study has been undertaken to determine whether it is possible for a set of standardized (simulated) patients to visit general practitioners, without being detected, in a health care system where doctors have fixed patient lists. Since sending standardized patients into doctors' offices is a new way to assess the performance of general practitioners; this paper describes in detail the methodology that has been used for visits. The paper looks first at the general preparation for visits and secondly at the specific preparation concerning the fine detail of the individual visit. The method was tested in 156 consultations with 39 general practitioners and in no cases were the standardized patients detected. None of the doctors visited felt offended and all were prepared to cooperate in future studies with standardized patients. It is concluded that the standardized patient method, following the step-by-step procedure described, is feasible in actual practice.

Clinical Competence↗
PubMed1991

Assessment of the performance of general practitioners by the use of standardized (simulated) patients.

A study was undertaken whereby a set of standardized (simulated) patients visited general practitioners without being detected, in a health care system where doctors had fixed patient lists. Thirty nine general practitioners were each visited during normal surgery hours by four standardized patients who were designed to be indistinguishable from real patients. The objective of the study was to see whether the actual performance of general practitioners, as assessed by standardized patients, met predetermined consensus standards of care for actual practice. The patients presented standardized accounts of headache, diarrhoea, shoulder pain and diabetes. The mean group scores of the doctors on the predefined standards of care for the different complaints ranged from 33 to 68%. The results show that standardized patients may be the method of choice in the assessment of the quality of actual care of doctors. It is hypothesized that the substandard scores of the doctors do not reflect inadequate competence, but are a result of the difference between competence and performance.

Clinical Competence↗
PubMed1990

Competence and performance: two different concepts in the assessment of quality of medical care.

In the debate about 'what is a competent general practitioner?' little attention has been paid ot the actual practice situation of general practitioners. This paper, based on the 18 most important studies in the literature about medical competence, tries to re-initiate this debate by proposing a clear distinction between 'competence', (what a physician is capable of doing) and 'performance' (what a physician does in his day-to-day practice). With this distinction we looked at whether studies defined both competence and performance, how they dealt with these concepts, what measurement instruments were used and what the conclusions of the studies were. Although it is the common reasoning that competence is a good predictor of performance this concept could not be affirmed. This survey shows that the majority of studies use wrong concepts and come to invalid conclusions. With the empirical distinction between competence and performance however, this paper proposes new directions for the quality assessment of general practitioners.

Clinical Competence↗
PubMed1988

Do personal computers make doctors less personal?

Ten months after the installation of a computer in a general practice surgery a postal survey (piloted questionnaire) was sent to 390 patients. The patients' views of their relationship with their doctor after the computer was introduced were compared with their view of their relationship before the installation of the computer. More than 96% of the patients (n = 263) stated that contact with their doctor was as easy and as personal as before. Most stated that the computer did not influence the duration of the consultation. Eighty one patients (30%) stated, however, that they thought that their privacy was reduced. Unlike studies of patients' attitudes performed before any actual experience of use of a computer in general practice, this study found that patients have little difficulty in accepting the presence of a computer in the consultation room. Nevertheless, doctors should inform their patients about any connections between their computer and other, external computers to allay fears about a decrease in privacy.

Attitude to Computers↗
PubMed1987

Simulated patients in general practice: a different look at the consultation.

To develop a better empirical basis for developing quality assessment in general practice three simulated patients made appointments with 48 general practitioners during actual surgery hours and collected facts about their performance. The simulated patients were indistinguishable from real patients and presented a standardised story of a symptomatic urinary tract infection. Two months later the same general practitioners received a written simulation about a patient who had the same urinary tract infection and were asked how they would handle this in real practice. Both results were scored against an existing consensus standard. The overall score for both methods did not show any substantial differences. A more differentiated analysis, however, showed that general practitioners performed significantly better with simulated patients. It also showed that general practitioners answering the written simulation performed significantly more unnecessary and superfluous actions. The results of this study show that the use of simulated patients seems to show the efficient performance of general practitioners in practice.

Family Practice↗