An assessment measure to evaluate case write-ups in a medicine core clerkship.
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Clinical Clerkship↗
Biomedical subjects
Judy A Shea
Publications and source records attributed to Judy A Shea.
Feasibility, reliability, and validity of the mini-clinical evaluation exercise (mCEX) in a medicine core clerkship.
PURPOSE: To determine the feasibility, reliability and validity of the mCEX when used to evaluate medical students' clinical skills in a medicine core clerkship. METHOD: In 2002, students were required to complete nine mCEX during their medicine clerkship. Mean mCEX scores were correlated with exam scores and course grades. RESULTS: 89% of targeted mCEX were completed. The reproducibility coefficient for eight mCEX was.77. Mean mCEX scores were significantly correlated with exam scores (r =.22; p =.004), inpatient (r =.43; p <.0001), outpatient (r =.35; p <.0001), and final course grades (r =.19; p =.014). CONCLUSIONS: These data support the feasibility, reproducibility, and validity of the mCEX in evaluating medicine clerkship students' clinical skills.
Clinical Clerkship↗
Effectiveness of report cards based on chart audits of residents' adherence to practice guidelines on practice performance: a randomized controlled trial.
BACKGROUND: Medical record audits have been used to provide physicians with feedback about their compliance with preventive health and disease management recommendations. PURPOSE: To determine if report cards summarizing medicine residents' preventive health and disease management practices can be used as a feedback tool to improve practice performance. METHODS: Randomized, blinded, controlled study of 44 internal medicine residents using an individualized 78-item report card based on outpatient record audits. RESULTS: Four hundred ninety-seven charts were retrospectively audited at baseline and 284 charts in follow-up. There were no significant differences in baseline performance between the residents in the intervention and control group. There were no differences in performance scores between residents receiving report cards and those who had not in immunizations, counseling, total preventive health, diabetes, hypertension, and total disease management. CONCLUSIONS: Intensive data-based feedback using report cards may not be a successful way to improve ambulatory performance of medical house officers.
Adult↗
Residents as members of intern selection committees: can they partially replace faculty?
BACKGROUND: Faculty involvement in the residency selection process is important, but increasing pressures on available faculty resources have made their ability to participate more difficult. Residents may be acceptable substitutions for some faculty in the selection process. PURPOSE: To test 2 new interview models and explore whether residents could partially replace faculty by examining what role the interview itself plays in the overall assessment of an applicant, comparing faculty and resident ratings of the interview, and asking whether partially substituting residents for faculty had an impact on the match outcome. METHODS: Applicants to an internal medicine residency program were assigned to 1 of 3 interview models: faculty-faculty, resident-faculty, resident-faculty-faculty. The 12 interview days were randomly assigned to a model and all applicants on each day had the same model. Interviewers used an applicant assessment form to assign ratings to 6 components of the portfolio and a final score. RESULTS: For both residents and faculty, the final score was highly correlated with the formal interview component. Within-model analyses showed residents consistently gave more favorable scores than faculty interviewers. There was no impact of interview model on initial or final rank position. Similarly, there was no difference between models in their match "success" rates. CONCLUSIONS: Residents can be successfully substituted for some faculty in the residency selection process. The use of residents does not impact the match results. Developing a small, committed group of interviewers should benefit both programs and applicants.
Analysis of Variance↗
Variation of mood and empathy during internship.
CONTEXT: Internship is a time of great transition, during which mood disturbances are common. However, variations in mood and empathy levels throughout the internship year have not been investigated. OBJECTIVE: To examine mood patterns and changes in empathy among internal medicine residents over the course of the internship year. DESIGN: Cohort study of interns involving completion of survey instruments at 4 points: time 1 (June 2000; Profile of Mood States [POMS] and Interpersonal Reactivity Index [IRI]), times 2 and 3 (November 2000 and February 2001; POMS), and time 4 (June 2001; POMS and IRI). SETTING: Internal medicine residency program at a university-based medical center. PARTICIPANTS: Sixty-one interns. MAIN OUTCOME MEASURES: Baseline scores of mood states and empathy; trends in mood states and empathy over the internship year. RESULTS: Response rates for time 1 were 98%; for time 2, 72%; for time 3, 79%; and for time 4, 79%. Results of the POMS revealed that physicians starting their internship exhibit less tension, depression, anger, fatigue, and confusion and have more vigor than general adult and college student populations (P<.001 for all). Results of the IRI showed better baseline scores for perspective taking (P<.001) and empathic concern (P =.007) and lower scores for personal distress (P<.001) among interns compared with norms. Five months into internship, however, POMS scores revealed significant increases in the depression-dejection (P<.001), anger-hostility (P<.001), and fatigue-inertia (P<.001) scales, as well as an increase in IRI personal distress level (P<.001). These increases corresponded with decreases in the POMS vigor-activity scores (P<.001) and IRI empathic concern measures (P =.005). Changes persisted throughout the internship period. CONCLUSIONS: We found that, in this sample, enthusiasm at the beginning of internship soon gave way to depression, anger, and fatigue. Future research should be aimed at determining whether these changes persist beyond internship.
Adult↗
Self-reported visual dysfunction in multiple sclerosis: new data from the VFQ-25 and development of an MS-specific vision questionnaire.
PURPOSE: To examine vision-specific health-related quality of life in a cohort of patients with multiple sclerosis (MS) using the 25-Item National Eye Institute Visual Function Questionnaire (VFQ-25), and to identify content areas for a brief MS-specific vision questionnaire. DESIGN: Cross-sectional survey. METHODS: The VFQ-25 and a modified version of the Optic Neuritis Treatment Trial (ONTT) Patient Questionnaire were administered by in-person interview to 80 patients at the University of Pennsylvania MS Center. Binocular visual acuities were obtained following a standard protocol using retroilluminated Early Treatment Diabetic Retinopathy Study charts. RESULTS: Despite a median binocular visual acuity of 20/16 (20/12.5-20/250), VFQ-25 subscale scores in the MS cohort were significantly lower (worse) compared with those of a published reference group of eye disease-free patients (P =.0001-0.009, two-tailed t tests). Rank-correlations of VFQ-25 composite (overall) scores with visual acuity were modest, but significant (r(s) = 0.33, P =.003), supporting construct validity for VFQ-25 scores in MS populations. Seven additional aspects of self-reported visual dysfunction in MS were also identified. CONCLUSIONS: Patients with MS have a high degree of self-reported visual dysfunction that is not entirely captured by visual acuity. The VFQ-25 is an effective measure of self-reported visual loss in MS. A brief MS-specific vision questionnaire may provide additional useful information when administered concurrently with the VFQ-25 in future investigations of MS and other neuroophthalmologic disorders.
Adult↗
Tensions in antibiotic prescribing: pitting social concerns against the interests of individual patients.
BACKGROUND: To reduce the prevalence of antibiotic-resistant bacteria in the community, physicians must optimize their use of antibiotics. However, optimal use from the perspective of the community (reserving newer agents for future use) is not always consistent with optimal use from the perspective of the individual patient (prescribing newer, broader agents). OBJECTIVES: To identify preferred patterns of antibiotic prescribing for patients with community-acquired pneumonia (CAP), measure explicit attitudes toward antibiotics and antibiotic resistance, and determine the relationship between these prescribing patterns and attitudes. DESIGN: Cross-sectional anonymous mail survey. PARTICIPANTS: National random sample of 400 generalist physicians (general internal medicine and family practice) and 429 infectious diseases specialists. MEASUREMENTS: Rank ordering of antibiotic preferences for a hypothetical outpatient with CAP and reasons for antibiotic selection. Endorsement of attitudes regarding antibiotic prescribing decisions and resistance. RESULTS: Both generalists and infectious diseases specialists were more likely to prefer newer, broader drugs for the treatment of CAP compared to older agents still recommended by national guidelines. Physicians rated the issue of contributing to antibiotic resistance lowest among 7 determinants of their choices. CONCLUSIONS: Despite national guidelines and increasing public awareness, the public health concern of contributing to the problem of antibiotic resistance does not exert a strong impact on physician prescribing decisions for CAP. Future efforts to optimize antibiotic prescribing decisions will need to consider options for increasing the impact of public health issues on the patient-oriented decisions of individual physicians.
Adult↗
Development and testing of a measure of health-related quality of life for men with urinary incontinence.
OBJECTIVES: To describe the development and psychometric testing of male versions of the Urogenital Distress Inventory (UDI) and Incontinence Impact Questionnaire (IIQ). DESIGN: Instrument development. SETTING: Urology clinic at a large urban Veterans Affairs Medical Center. PARTICIPANTS: Convenience sample of English-speaking community-dwelling male urology clinic patients who acknowledged concerns about urine leakage. MEASUREMENTS: Content experts and male clinic patients evaluated items for clarity and fit. Revised instruments were administered to 153 participants. Data were analyzed to examine issues of feasibility of administration, internal consistency reliability, and validity. RESULTS: Modal completion time for the Male Urogenital Distress Inventory (MUDI) (27 items) and Male Urinary Symptom Impact Questionnaire (MUSIQ) (32 items) was 20 minutes. Cronbach's coefficients were.89 for the MUDI and.95 for the MUSIQ. Total MUDI and MUSIQ scores were moderately correlated (r =.59, P <.001). Mean MUDI and MUSIQ scores varied significantly with self-reported desire for socialization, urine leakage, and depression. Principal components analyses suggested the presence of seven factors accounting for 65.4% of the variance in the MUDI and six factors accounting for 72.9% of the variance in the MUSIQ. CONCLUSIONS: It is feasible to use the MUDI and MUSIQ to measure health-related quality of life in men with continence problems. The scores appeared to be reliable and valid in this racially and educationally diverse sample. Use of the MUDI and MUSIQ may provide more sensitive measurement of the specific effect of urinary incontinence and related symptoms on health-related quality of life in men. Future research should determine reproducibility and responsivity and reexamine the construct validity of these instruments.
Aged↗
Implementation of the mini-CEX to evaluate medical students' clinical skills.
OBJECTIVE: The majority of medicine clerkships use faculty and resident summative ratings to assess medical students' clinical skills. Still, many medical students complete training without ever being observed performing a clinical skill. The mini-CEX is method of clinical skills assessment developed by the American Board of Internal Medicine for graduate medical education. The brief, focused encounters are feasible and produce scores with adequate reproducibility if enough observations are made.(1) The mini-CEX has been used in the medicine core clerkship, being performed once to augment feedback by faculty evaluators in the inpatient setting.(2) However, additional study is needed to address at least two feasibility issues if the mini-CEX is to be used as a measurement tool: (1) multiple settings (inpatient and outpatient) and (2) resident-completed evaluations. Our objective was to determine the feasibility of having students receive multiple mini-CEX's in both the inpatient and outpatient settings from resident and faculty evaluators. DESCRIPTION: We introduced the mini-CEX into our nine-week medicine clerkship (six weeks inpatient and three weeks outpatient) in July 2001. The clerkship uses four inpatient clinical sites and 16 outpatient practices. Inpatient faculty rotate on two-week blocks and residents on four-week blocks. At our clerkship orientation, each student (n = 39) received a booklet of ten adapted mini-CEX forms. In the mini-CEX, students are observed conducting a focused history and physical examination and then receive immediate feedback. Students are rated in seven competencies (interviewing, physical examination, professionalism, clinical judgment, counseling, organization, and overall clinical competence) using a nine-point rating scale (1 = unsatisfactory and 9 = superior). Our students were instructed to collect nine evaluations: three from faculty (one every two weeks), three from residents (one every two weeks), and three from their out-patient attendings (one per week). Students and evaluators were asked to rate their satisfaction with the exercise using a nine-point scale (1 = low and 9 = high). Students were asked to turn in their booklets the day of the exam. Prior to implementation, we reviewed the mini-CEX forms and rationale for use with residents and inpatient faculty. Similar information was mailed to outpatient faculty preceptors. DISCUSSION: Booklets were received from 32 students. The mean number of evaluations completed per student was 7.3 (range 2-9), for a total of 232 evaluations. Faculty completed 58% of the evaluations; 68% were from the inpatient setting. The observation and feedback took an average of 21 minutes and 8 minutes, respectively. Satisfaction with the exercise was rated by faculty/residents as 7.2 and by students as 6.8. We believe these findings support the feasibility of collecting multiple mini-CEX assessments from both inpatient and outpatient sites using faculty and resident evaluators. The feasibility of collecting multiple assessments is important if the mini-CEX is to be a reproducible assessment of clinical skills. Having established feasibility, we plan to look at the reproducibility and validity of mini-CEX scores in order to determine if it can be used as a formal means of clinical skills assessment. We also plan to evaluate the impact on the quality and specificity of end-of-clerkship summative ratings.
Clinical Competence↗
Evaluations of clinical faculty: the impact of level of learner and time of year.
BACKGROUND: Because of the importance of faculty evaluation data for faculty development, promotion, reappointment, and remuneration, the quantity and characteristics of evaluation data need study. PURPOSES: To examine differences in evaluation ratings according to level of learner (student vs. resident) and time of year. METHODS: Retrospective analyses of 1,281 faculty evaluations provided for 132 faculty over a 12-month period by students and residents on inpatient medicine rotations. RESULTS: Faculty had an average of eight evaluations over a year. Students gave more favorable ratings than residents. Over the year, students became less critical and residents became more critical. Winners of teaching awards had better evaluations than other faculty. Standard errors around mean ratings for an individual faculty member were approximately 0.25 on a 4-point scale. CONCLUSIONS: The profile and precision of assessments for an individual will vary based on the number, timing, and source of ratings. Decisions based on similar data should be made with caution.
Faculty, Medical↗
Literacy and knowledge, attitudes, and behavior about colorectal cancer screening.
This cross-sectional survey explored the association between functional health literacy and knowledge of, beliefs and attitudes about, and reported usage of colorectal cancer screening tests. The results indicate that functional health literacy, as assessed by the Short Test of Functional Health Literacy in Adults (STOFHLA), is not an independent predictor of colorectal cancer screening knowledge, beliefs, attitudes, or behavior. Latino ethnicity and education, however, often predicted screening responses, suggesting that efforts to improve communication about colorectal cancer screening with Latino patients and patients with low education clearly are needed to reduce the disparities in awareness and utilization of colorectal cancer screening tests. This study also explored influences on intended screening behavior. Physician recommendation was found to be a powerful motivator of intention to undergo colorectal cancer screening regardless of literacy level, indicating that interventions aimed at increasing physician recommendation of colorectal cancer screening may be an effective way of increasing screening rates.
Acculturation↗
Antibiotic prescribing decisions of generalists and infectious disease specialists: thresholds for adopting new drug therapies.
The objective of this study was to examine whether physicians are willing to continue to use older antibiotics in the face of drug resistance in order to preserve newer antibiotics forfuture use. The study was a national sample of 398 generalist physicians and 429 infectious disease (ID) specialists. Clinical vignettes prompted respondents to select the level of resistance to a hypothetical older antibiotic at which they would prefer a newer antibiotic without any current resistance in the treatment of a patient with pneumococcalpneumonia. Vignettes varied in the site of care of the patient as a proxyfor variation in disease severity. Respondents significantly reduced their threshold for switching to a newer antibiotic as disease severityincreased. Generalists were more responsive to disease severity than LD specialists. Thus, the adoption of recommendations to limit overuse of newer antibiotics may be variable across clinical settings and providers, reducing the impact of these recommendations on emerging resistance.
Adult↗
Factors associated with undertreatment of medical student depression.
The authors measured factors associated with under-treatment of medical students' depression. They administered a cross-sectional Beck Depression Inventory and sociodemographic questionnaire to students at 1 medical school, defining their outcome measure as the use of counseling services or antidepressant medication. Of an estimated 450 available student participants in the study, 322 (71.6%) completed the questionnaire. Forty-nine students (15.2%) were classified as depressed and 10 (20.4%) reported experiencing suicidal ideation during medical school, but only 13 (26.5%) of the depressed students reported treatment. The researchers observed no difference in treatment by year in school, completion of psychiatric requirement, race, or depression severity. Treatment for depression was significantly associated with older age and personal and family histories of depression. Despite the availability of effective medications and confidential mental health services, medical students with depression are undertreated. The authors' findings support the need for targeted messages to help medical students recognize their depression and refer themselves for appropriate treatment.
Adult↗