Assessing the reliability and validity of the mini-clinical evaluation exercise for internal medicine residency training.

PURPOSE: The mini-clinical evaluation exercise, or mini-CEX, assesses residents' history and physical examination skills. To date, no study has assessed the validity of the mini-CEX (mCEX) evaluation format. The authors' objective was to determine the reliability and validity of the mCEX evaluation format. METHOD: Twenty-three first-year residents at Wright-Patterson Medical Center in Dayton, Ohio, were included in the study (academic years 1996-97, 1997-98, and 1998-99). Validity of the instrument was determined by comparing mCEX scores with scores from corresponding sections of a modified version of the standard American Board of Internal Medicine's (ABIM's) monthly evaluation form (MEF) and the American College of Physicians-American Society of Internal Medicine In-Training Examination (ITE). All ABIM MEFs were used without exclusionary criteria, including ABIM MEFs from months where a corresponding mCEX evaluation was not performed. RESULTS: Each resident in the study had an average of seven mCEX evaluations and 12 ABIM MEFs. Of the 168 required mCEX evaluations, 162 were studied. Internal consistency reliability was .90. Statistically significant correlations were found for the following: mCEX history with ABIM history; mCEX physical exam with ABIM physical exam; mCEX clinical judgment with ABIM clinical judgment, medical care, medical knowledge, and the ITE; mCEX humanistic attributes with ABIM humanistic attributes, and mCEX overall clinical competence with ABIM overall clinical competence, medical care, medical knowledge, and the ITE. Analysis of variance comparing sequential mean mCEX scores yielded no significant difference. CONCLUSIONS: This study suggests that the mCEX is a feasible and reliable evaluation tool. The validity of the mCEX is supported by the strong correlations between mCEX scores and corresponding ABIM MEF scores as well as the ITE.     

Qualities and attributes desired in menopause clinicians

OBJECTIVE: To assess the qualities and attributes desired in menopause clinicians. DESIGN: Women > or =45 years of age (n=72) were surveyed about the qualities and attributes desired in their physician. Surveys were performed in physician waiting rooms in Connecticut. RESULTS: Although fewer men are entering the practice of ObGyn, more than 88% of peri- and post-menopausal women believe that gender does not affect the quality of their women's health provider. Among the 68 women from whom valid data were obtained, experience (95.6%), knowledge (95.6%), and ability (92.6%) were the most important qualities. Only 4.2% listed gender in the top three most important qualities. If the patient's visit was for wellness- and screening-related issues, 6.6% (n=4) preferred a male, 13.1% (n=8) preferred a female, and 80.3% (n=49) had no preference for gender. The percentage of patients preferring to see a female was slightly higher (29.2%) if the visit was for a pelvic exam, while the percentage preferring to see a male (14.5%) was greater if care involved gynecological surgery. CONCLUSIONS: As medical practices meet the increasing demand of menopausal women, it is helpful to know the qualities and attributes that patients desire. Menopause clinicians should seek to convey experience, knowledge, and competence to their patients. A menopause practice should strive for a well-diversified team that will bring these qualities to menopausal patients. Given the shifting balance of male and female ObGyn providers, when hiring providers or establishing a menopause clinic, it is helpful to know that gender diversification is of minor importance.     

Recognition can leave room for disagreement in the doctor-patient consultation

Objective

We wanted to explore how recognising interaction, as described by psychologist Schibbye, is played out in a patient doctor encounter including the behaviour of both parties and their simultaneous communication.

Methods

We selected videotapes from five doctor–patient encounters where a recognising attitude was identified. The episodes were analysed using a qualitative method for studying interaction and relationship at the micro-level. We describe an episode which is suitable for demonstrating how a recognizing attitude can leave room for disagreement.

Results

The doctor's recognising attitude with a basic respect for the other person's experience perspective has a crucial effect on the doctor–patient relationship. In this consultation, the doctor succeeds in taking the patient's experience perspective by listening, wondering and exploring to check that he has interpreted the patient correctly. A potential conflict situation arises, but there is no conflict. When the relationship is characterised by recognition, disagreement is allowed, without doing any damage.

Conclusion

Schibbye's ideas and terms can provide new perspectives on the doctor–patient interaction.

Practice implications

For the doctor, a fundamental respect for the patient's perspective may make it easier to tolerate when patients have values and preferences that conflict with the doctor or with sound medical practice.     

An augmented reality tool for learning spatial anatomy on mobile devices

Augmented Realty (AR) offers a novel method of blending virtual and real anatomy for intuitive spatial learning. Our first aim in the study was to create a prototype AR tool for mobile devices. Our second aim was to complete a technical evaluation of our prototype AR tool focused on measuring the system's ability to accurately render digital content in the real world. We imported Computed Tomography (CT) data derived virtual surface models into a 3D Unity engine environment and implemented an AR algorithm to display these on mobile devices. We investigated the accuracy of the virtual renderings by comparing a physical cube with an identical virtual cube for dimensional accuracy. Our comparative study confirms that our AR tool renders 3D virtual objects with a high level of accuracy as evidenced by the degree of similarity between measurements of the dimensions of a virtual object (a cube) and the corresponding physical object. We developed an inexpensive and user‐friendly prototype AR tool for mobile devices that creates highly accurate renderings. This prototype demonstrates an intuitive, portable, and integrated interface for spatial interaction with virtual anatomical specimens. Integrating this AR tool with a library of CT derived surface models provides a platform for spatial learning in the anatomy curriculum. The segmentation methodology implemented to optimize human CT data for mobile viewing can be extended to include anatomical variations and pathologies. The ability of this inexpensive educational platform to deliver a library of interactive, 3D models to students worldwide demonstrates its utility as a supplemental teaching tool that could greatly benefit anatomical instruction. Clin. Anat. 30:736–741, 2017. © 2017Wiley Periodicals, Inc.     

Physician–patient communication in single-bedded versus four-bedded hospital rooms

Objective

To examine whether physician–patient communication in multi-bedded rooms differs from communication in single rooms during ward rounds.

Methods

Ward rounds in single-bedded patient rooms and ward rounds in four-bedded rooms were audiotaped and analyzed with an adapted version of MIARS. The researcher completed an observational checklist of each encounter. We measured: the duration of speech time, the types of verbal and nonverbal communication, the extent to which patients and physicians raise intimate subjects.

Results

Encounters during ward rounds in single rooms significantly took up more time than encounters in four-bedded rooms. The patients asked more questions and made more remarks in single rooms compared to four-bedded rooms. Empathic reactions of the physician were scored significantly more often in single rooms than in four-bedded rooms. No differences were observed concerning the extent to which intimate subjects were brought up.

Conclusion

This study is the first that investigated this subject. Findings suggest that single rooms contribute positively to physician–patient communication.

Practice implications

The research findings indicate the relevance of taking account of the context in which physician–patient communication takes place.     

Factors associated with patient reports of positive physician relational communication

Objective

To evaluate the patient, physician, and visit-related factors associated with patient ratings of positive physician relational communication.

Methods

Pre- and post-visit surveys were conducted with 485 patients attending a routine periodic health exam with one of 64 participating physicians. The audio-recorded visits were coded for elements of patient–physician communication including assertive responses, partnership building, question asking, supportive talk, and expressions of concern.

Results

Patient reports of positive physician relational communication were associated with patient perceptions of how well the physician understood the patient's health care preferences and values, a patient–physician interaction outside of the exam room, and physician-prompted patient expressions of concern.

Conclusion

In addition to a patient's perception of their relationship with their physician going into the visit, relatively simple acts like extending the interaction beyond the exam room and ensuring that patients feel invited to express concerns they may have during the visit may influence patient perceptions of physician relational communication.

Practice implications

This study offers preliminary support for the idea that relational communication and its associated benefits may be fostered through simple physician-driven acts such as interacting with patients outside of the exam room and encouraging patients to express concerns within the visit.     

Empathy in computer‐mediated interactions: A conceptual framework for research and clinical practice

Empathy plays a crucial role in fostering positive social interactions and is elicited through verbal and nonverbal socioemotional cues. Computer‐mediated communication (CMC) rapidly connects individuals at a distance but can partly filter out nonverbal cues. We draw from available telehealth and emotion communication literature to elaborate a cohesive conceptual framework of online empathy, a tool the field is currently lacking. The distinctive features of online communication and their impacts on the empathic interaction are described. We also detail strategies that users can employ to facilitate feeling, conveying, and being perceived as empathic in CMC.     

Behavioral observations of sensory substitution in neonate macaques (Macaca arctoides)

The ability of neonate macaque monkeys to learn to respond to artificial spatial sensory information was studied through the use of compact, head-worn, electronic spatial sonars with audible displays, which translate spatial information into auditory dimensions specifying distance, direction, and surface characteristics. Three animals were born in the dark and raised without vision for 1 to 3 months while wearing either the Binaural Sensory Aid (Animal 1; Kay, 1974) or the Trisensor (Animals 2 and 3; Easton & Jackson, 1983) airborne sonars. Each animal demonstrated alertness to information transmitted by the devices in spontaneous reaching or reinforced discrimination tasks, and more device-related, perceptual-motor activities were observed when the sensors were switched on than when they were switched off. The results show that neonate monkeys can learn effective use of information obtained from sensory substitution devices through unstructured interaction with the environment.     

3-D visualization and animation technologies in anatomical imaging

This paper explores a 3‐D computer artist’s approach to the creation of three‐dimensional computer‐generated imagery (CGI) derived from clinical scan data. Interpretation of scientific imagery, such as magnetic resonance imaging (MRI), is restricted to the eye of the trained medical practitioner in a clinical or scientific context. In the research work described here, MRI data are visualized and interpreted by a 3‐D computer artist using the tools of the digital animator to navigate image complexity and widen interaction. In this process, the artefact moves across disciplines; it is no longer tethered to its diagnostic origins. It becomes an object that has visual attributes such as light, texture and composition, and a visual aesthetic of its own. The introduction of these visual attributes provides a platform for improved accessibility by a lay audience. The paper argues that this more artisan approach to clinical data visualization has a potential real‐world application as a communicative tool for clinicians and patients during consultation.     

Cognition of binary-event-sequences: its relation to the sequential attributes

Sixty subjects were asked to evaluate the degree of similarity among 15 binary-event-sequences which were generated through the Bernoulli process. The averaged similarity matrix of 50 subjects (ten omitted) was analysed by the Hayashi's Quantification Method IV, and the dimensions yielded were compared with the theoretically derived dimensions for the operational interpretation. The result showed that the run structure--the number of runs and the length of the longest run--and the number of one event in a sequence were the important attributes in cognition of binary-event-sequences. These attributes were most frequently employed by subjects, although other attributes and their combinations may be relevant. It was pointed out that the general tendency of judgments, i.e., dependence on the spatial and visual aspects of given sequences, proved subjects' inattention to the characteristics of the probabilistic generation process of sequences.     

New medical licensing examination using computer-based case simulations and standardized patients.

PURPOSE: To evaluate a new method, used for the first time in Italy, of administering the Medical Licensing Examination (MLE). METHOD: Eighty medical school graduates taking the MLE were studied. The MLE was based on the Multimedia Integrated Pilot Project (MIPP), a single two-step examination that combines computer-based case simulations (step 1) and clinical encounters using standardized patients (step 2). Step 1 assessed mainly clinical knowledge and decision-making skills. Step 2 measured the ability to obtain a focused history, perform a relevant physical examination, prioritize a differential diagnosis and management plan, and provide patient education or counseling. The correlations between the total MIPP scores and the exam scores students obtained during the six-year medical school curriculum were evaluated. RESULTS: The step 1, step 2, and total MIPP scores were moderately correlated with the curriculum scores. A moderate correlation also existed between the scores reported in step 1 and those of step 2. CONCLUSIONS: The MIPP is a good tool for assessing clinical competence. Internationally, computer-based and standardized patient assessments are being used more often in licensing examinations. Continuous use of this method could improve medical graduates' performances.     

Distance-dependent interactions between the rod and the cone systems in goldfish retina

Summary We recorded from ganglion cell axons in the optic tracts of self-respiring goldfish, and examined the interaction of rod-effective and cone-effective stimuli within their receptive fields. The summation of influences due to the rod system and the long wavelength sensitive cone system was analyzed by the methods of response-summation and sensitivity-summation. Different spatial relationships between the rod- and cone-effective stimuli allowed examination of distance-dependent effects.Both the response-summation and sensitivity-summation analyses showed a difference in non-linearity between a configuration in which the rod-and cone-effective stimuli were spatially overlapped and a configuration in which they were not. This difference in both analyses demonstrates a distance dependent interaction between the rod and cone systems. Both analyses also showed a difference in non-linearity between a configuration in which the rod- and cone-effective stimuli were nearby (but not overlapped) and one in which they were more distant. This demonstrates that the interaction is not limited to receptors that are immediate neighbors. An estimate of the strength of interaction in each case showed that the differences among the three configurations were relatively slight, indicating a broad spread of the effect. The interaction was found to be relatively powerful; assuming a specific simple model for the interaction mechanism, we found that each system exerts an effect upon the other which accounts for about 1/3 of its signal.Supported by grant no. 5 R01 EY 01951 from the National Eye Institute of NIHSupported by Research Fellowship no. 5 F32 NS05438 from NINCDS of NIH     

Telemedicine: a useful tool for the pediatric cardiologist.

OBJECTIVE: To determine if the Georgia Statewide Academic and Medical System Telemedicine Network can deliver subspecialty pediatric care to rural areas of Georgia. MATERIALS AND METHODS: A retrospective review was conducted of a clinical experience, over a 30-month period from November 1993 through June 1996, involving 13 pediatric cardiology-related encounters in seven male and six female patients. Patients' ages ranged from 5 days to 16 years. Eleven encounters were initiated because of a suspicion of congenital heart disease (CHD); two encounters involved postoperative evaluations in patients who had recently undergone cardiac surgery at the Medical College of Georgia (MCG). RESULTS: Of the 11 patients suspected to have CHD, five had CHD documented during the telemedicine evaluation, of whom two were transferred to MCG for further invasive evaluation and surgical correction. Three others with CHD, and the remaining six patients who required no further subspecialty follow-up, were followed in their home communities by their primary care physicians. CONCLUSIONS: Telemedicine is a useful tool for the evaluation of infants and children with suspected CHD.     

Effects of castration, blindness and anosmia on social reactivity in the male Mongolian gerbil (Meriones unguiculatus)

The effects of a varied set of hormonal and sensory variables were analyzed in terms of their impact upon social encounters between pairs of male gerbils. Control observations were employed to assess effects of these variables on behavior in the test situation when no other animal was present. Castration was found to increase aggression between male gerbils, without changing the basic patterns of solitary behavior. Removal of visual input (through blinding) resulted in some increment in aggressive interactions and marked facilitation of locomotor activity. Alternately, anosmia produced either through bilateral removal of the olfactory bulbs, or as the result of treatment of the peripheral mucosa with zinc sulphate, resulted in a general reduction in social interaction despite a moderate increment in locomotor activity.     

How patients perceive a doctor's caring attitude

OBJECTIVE: Caring is closely associated with reduced malpractice litigation, adherence to treatment and even symptom relief. Caring also is included in pay for performance formulas as well as widely utilized for quality improvement purposes. Our objective in this prospective qualitative study was to define caring behaviors associated with three challenging encounters: discussing the transition from curative to palliative care, delivering bad news (cancer), and discussing a medical error (misplaced test result). The purpose was to lay the groundwork for the creation of a 'patient-centered' caring attitude checklist that could help the healthcare provider understand and ultimately enhance the patient's experience of care. METHODS: Groups of randomly selected lay people, henceforth referred to as patients: (1) engaged in 'think aloud' exercises to help create a 15-item caring behavior checklist; (2) used the checklist to rate videotapes of simulated challenging encounters conducted by twenty primary care physicians (total of 600 ratings sets); and (3) participated in 12 separate 1.5h focus groups discussing the caring (and non-caring) behaviors exhibited in videotapes of the highest and lowest rated encounters. RESULTS: Thirteen behaviors emerged as focal for describing a doctor's caring attitude but with disagreement as to whether specific examples of these behaviors were 'caring' or 'uncaring.' For example, although the concept of empathic inquiry was considered important by most patients, the physician question, "Is there someone you can call or talk with" (about a cancer diagnosis) was interpreted by one patient as 'very caring' while another was 'impressed with how uncaring' the statement appeared. CONCLUSION: At the conceptual level there is a set of behaviors that represent caring, however, the manifestation of these behaviors is 'in the eye of the beholder.' The most important element of caring may not be the set of behaviors but a set of underlying abilities that include taking the patient's perspective and reflecting on the patient's responses. PRACTICE IMPLICATIONS: Medical education must focus on the underlying abilities of caring.     

Self-Determination Theory to observe healthcare professionals’ counselling in chronic care encounters: Development of the COUNSEL-CCE tool

ObjectiveTo develop and psychometrically evaluate an observation tool to rate healthcare professionals’ engagement in need-supportive and need-thwarting counselling in chronic care encounters.MethodsThe observation tool was developed through three stages (January 2018 – June 2019). First, a set of items was developed according to essential components of need-supportive and need-thwarting counselling as identified in Self-Determination Theory. Second, content validation by five experts. Third, ecological validation using video-recorded real-life consultations. For the psychometric evaluation (June – October 2019), the tool was used by three observers to code 55 units of real-life encounters.ResultsThe Coding and Observing Need-Supportive Counselling in Chronic Care Encounters (COUNSEL-CCE) consists of 44 items clustered into nine theoretically underpinned behavioural approaches. Psychometric testing indicated acceptable to good consistency in scoring between observers and strong consistency within observers.ConclusionThe COUNSEL-CCE captures person-oriented alongside process-oriented aspects during chronic care encounters. A person-oriented approach expresses counselling that is responsive to individual preferences and needs, whereas a process-oriented approach indicates the necessity to support competency building within patients, and is more instrumental of nature.Practice implicationsCOUNSEL-CCE is a valuable observation tool to assess (graduate) healthcare professionals’ counselling style and address if, and how, counselling evolves as a result of professional training.     

Effects of video interaction analysis training on nurse-patient communication in the care of the elderly

This paper describes an empirical evaluation of communication skills training for nurses in elderly care. The training programme was based on Video Interaction Analysis and aimed to improve nurses' communication skills such that they pay attention to patients' physical, social and emotional needs and support self care in elderly people. The effects of the training course were measured in an experimental and control group. They were rated by independent observers, by comparing videotapes of nursing encounters before and after training. Forty nurses participated in 316 videotaped nursing encounters. Multi-level analysis was used to take into account similarity among same nurse encounters. It was found that nurses who followed the training programme, provided the patients with more information about nursing and health topics. They also used more open-ended questions. In addition, they were rated as more involved, warmer and less patronizing. Due to limitations in the study design, it could not be demonstrated that these findings can entirely be ascribed to the training course. Further research, incorporating a randomized controlled design and larger sample sizes, is recommended to determine whether the results can be attributed to this specific type of training.