Promoting diagnostic problem representation

PURPOSE: Problem representation, as mediated by semantic qualifiers (SQs), has been associated with better diagnostic outcomes. The purpose of this study was to assess the effect of training medical students to use semantic abstractions as a means of building problem representations. METHODS: Sixty second-year medical students were assigned to either an intervention group (n = 20) or a control group (n = 40) during 8 months of an Essentials in Clinical Medicine course which used standardized patient-based workshops. Students were trained to transform findings into SQs and to use abstractions to compare and contrast diagnostic hypotheses. Students were assessed using a standardized patient data collection checklist, a post-encounter patient finding questionnaire (PFQ), and case summaries and write-ups. RESULTS: Experimental subjects used over twice as many SQs in their summaries as control group members (1.40 versus 0.63, P = 0.006). The correlation between checklist and PFQ scores was higher for the experimental group than for the control group (r = 0.70 versus r = 0.58, P 0.56). CONCLUSION: A short instructional intervention was successful in promoting the use of SQs and enabled students to recall elicited findings better. This intervention did not enhance data interpretation and diagnostic accuracy. Use of SQs may therefore be a necessary tool for efficient problem representation but one that is insufficient when used in isolation. The naturalistic setting used in this study imposed a number of limitations, implying that further research should test whether instructional efforts should also emphasize recognition of key patient findings and knowledge representation.     

Clinical problem solving and clinical knowledge

Videotape and simulated patients were used for evaluating third year medical students' performances in solving familiar and unfamiliar clinical problems. To assist the doctor to rate the students' performances by the review of videotapes, criteria were set up for students' behaviours that could be construed as evidence that the students recognized cues obtained by interviewing the patient and the information content of such cues. Criteria for data use by the students were also set. A mean of 90% of the pertinent medical history data was collected by the students. The amount of pertinent historical data collected was found to correlate very closely with student-patient interaction analysis score for the familiar and unfamiliar problems (r = 0.89 and r = 0.92, respectively). Significant differences in mean scores for data generation (P less than 0.001) and for data use (P less than 0.01) were found between those students who solved and those who failed to solve the familiar problem. With the unfamiliar problem a significant difference was found between the mean scores for data generation (P less than 0.01), but not for data use. The implications of these findings in medical education are discussed.     

Problems of research into medical problem solving: some remarks on theory and method

Investigators of medical problem solving, and of problem solving in general, appear to use the term problem solving to denote different concepts.
Medical problem solving sometimes refers to the doctor solving the patient's problem, whereas others use it to refer to the doctor solving his own diagnostic problem. Second, 'problem' is used by some in a subjective sense (something is only called a problem if the subject has difficulties with it), and by others in an objective sense (problem being nearly synonymous with task). Finally, there is the definitional question of whether knowledge and problem solving are regarded as independent or as intimately related.
What one means by problem solving, with one's research objectives (research may be aimed at medical education, medical practice or cognitive theory), constitute the major determinants of the choice of research design.
It is advocated that investigators, before selecting a research design, should clarify their own definitions and research objectives, and before adopting other investigators' definitions and research designs, should consider carefully their research objectives.     

The students' view of an innovative undergraduate medical course: the first year at the University of Newcastle,N.S.W.†

An innovative medical course commenced in 1978 in a new medical school at the University of Newcastle. An evaluation of the student response to the first year of this course was carried out. This evaluation aimed to assess how far the students had progressed towards the attainment of the long-term Faculty objectives on which the Newcastle curriculum is based. Students' perceptions of educational innovations were obtained and compared with the Faculty's stated aims. Students felt that they could approach a problem scientifically, in a manner consistent with the Faculty's specified methods. In the area of team work, students had accepted the need for training in team skills as preparation for work after graduation. Students have adapted to the use of objectives, to assessment for competence, and to the marking of one another's papers. These methods had been introduced to facilitate the development of skills necessary for independent and continuing self-education. Patient contact was designated as the greatest strength of the first year. Students expressed concern for patient well-being and the influence of student activities on patients. This indicated that students had progressed some way towards the attainment of the Faculty objective that they should develop an humanitarian approach to patients.     

幼儿应对方式对幼儿问题行为的影响

目的 探讨了幼儿的应对方式、应对方式在父母教养方式、幼儿的问题行为之间的中介作用。方法 采用情境故事评价的方法、幼儿父母教养方式问卷、Achenbach幼儿问题行为量表分别测查幼儿的应对方式、幼儿父母的教养方式以及幼儿的问题行为。结果 3～5岁幼儿对应对策略的采用具有情境差异性;4、5岁儿童的问题趋向应对比例均数（分别为0．42±0．28,0．41±0．30）显著大于3岁儿童（0．21±0．19）;问题趋向应对对幼儿的外显和内隐问题行为均有明显的负向预测作用,且在父母的教养方式影响儿童的问题行为中起到部分的中介作用。结论随着年龄的增长,幼儿的应对方式渐趋成熟。问题趋向应对是一种积极的应对方式,可有效预防幼儿的问题行为。     

A review of the evaluation of clinical teaching: new perspectives and challenges

PURPOSE: This article discusses the importance of the process of evaluation of clinical teaching for the individual teacher and for the programme. Measurement principles, including validity, reliability, efficiency and feasibility, and methods to evaluate clinical teaching are reviewed. CONTEXT: Evaluation is usually carried out from the perspective of the learner. This article broadens the evaluation to include the perspectives of the teacher, the patient and the institutional administrators and payers in the health care system and recommends evaluation strategies. RESULTS: Each perspective provides specific feedback on factors or attributes of the clinical teacher's performance in the domains of medical expert, professional, scholar, communicator, collaborator, patient advocate and manager. Teachers should be evaluated in all domains relevant to their teaching objectives; these include knowledge, clinical competence, teaching effectiveness and professional attributes. CONCLUSIONS AND IMPLICATIONS: Using this model of evaluation, a connection can be made between teaching and learning about all the expected roles of a physician. This can form the basis for systematic investigation into the relationship between the quality of teaching and the desired outcomes, the improvement of student learning and the achievement of better health care practice. It is suggested that the extent of effort and resources devoted to evaluation should be commensurate with the value assigned to the evaluation process and its outcomes.     

Assessment of undergraduate general practice teaching

Final-year medical students at the University of Bristol were asked to outline a plan of management for an elderly female patient who presented with several problems. These problems were presented in the form of a 'patient management questionnaire'. This questionnaire was completed before and again after a 9-week course that included a 3-week attachment to two general practitioners. The patterns of answers were compared to look for modifications in the plan of management that could be attributed to the teaching. The results indicate a broader plan of management after the course with more students considering the physical, social and family needs of the patient, rather than the clinical problems alone. Nevertheless, further experience of this method of assessment is needed before the technique can be considered a useful tool in the evaluation of general practice teaching.     

Preparation and presentation of patient-management problems (PMPs)

This booklet offers some guidance to the teacher who wishes to produce patient-management problems for use with his students for teaching or assessment. The producer should be familiar with the four phases of problems. The first phase is the provision of information about the patient, the second the request for some action from the respondent, the third the feedback to the respondent and the final phase the conclusion of the problem. PMPs simulate reality and reproduce the decisions a doctor has to make in investigating and managing a patient. The respondent has to be involved actively in the problem. This is facilitated by: the use of the personal rather than impersonal, for example, 'You are called to see a man...' rather than 'Mr C consults his doctor...'; the use of the present rather than the past tense; provision of the results of the physical examination and investigation as they relate to the patient; alteration of the patient's status according to the actions taken by the respondent. (This may be possible only with computer-based PMPs). A range of media can be used to present problems including print, audiotape, slides, filmstrip, microfiche, overhead projector transparencies, videotape, film, computers, models and simulated patients. Each technique has advantages and disadvantages.     

Adrenal incidentaloma: a clinical problem related to imaging

Two female patients, 68 and 67 years of age, were referred for right abdominal pain and pyelonephritis, respectively. During the diagnostic work-up, an unsuspected adrenal mass was found in both patients. Hormonal evaluation and imaging showed a benign non-hyperactive functioning adenoma in one patient and a pheochromocytoma in the other. Both patients were successfully treated with endoscopic adrenalectomy. Wider application and improvement of abdominal imaging procedures have caused an increase of incidentally detected adrenal masses, posing a common clinical problem. Typically, a diagnosis can be made on the basis of the characteristic radiological image. The exact nature of the defect is often unclear and further evaluation is required to determine functionality and possible malignancy. An algorithm is presented for the management of adrenal incidentalomas.     

绘画团体辅导对小学生问题行为及亲子关系质量干预效果评价

  目的  探索绘画团体辅导对小学生问题行为及亲子关系质量的干预效果,为促进小学生心理健康提供一种新的思路和实操方法。  方法  对某小学四年级全体学生随机选取其中两个班分别为实验组和对照组,进行为期8周的绘画团体辅导实验, 采用Conners儿童行为问卷、问题解决量表和家长接纳问卷为评估工具。  结果  组间比较显示,干预前实验组(27.59%)与对照组(15.38%)的问题行为检出率差异无统计学意义(Z=1.10,P>0.05),干预后实验组问题行为检出率的降低程度(17.24%)高于对照组(3.85%)(Z=3.71,P < 0.01);干预前两组在问题解决和家长接纳的得分上差异均无统计学意义(t值分别为0.63,0.38,P值均>0.05),干预后实验组的问题解决得分低于对照组(t=-2.28,P < 0.05),家长接纳得分高于对照组(t=2.57,P < 0.05)。组内比较显示,干预后实验组的问题行为和问题解决得分均比干预前降低(t值分别为2.56,2.44),而家长接纳得分比干预前提高(t=-2.26)(P值均 < 0.05);对照组各变量的得分在干预前后的差异均无统计学意义(P值均>0.05)。重复测量方差结果显示,问题行为的主效应、问题解决和家长接纳的交互效应均有统计学意义(F值分别为8.63,8.01,4.62,P值均 < 0.05)。  结论  绘画团体辅导能减少小学生的问题行为,并提高其亲子关系质量,可在小学心理健康教育中应用,为促进小学生健康成长发挥积极的作用。     

An evaluation of a course for undergraduate teaching of general practice

This paper presents an evaluation of the undergraduate fifth year course of teaching in general practice in the Queen's University, Belfast. Two Modified Essay Question papers were randomly selected from those used for some years past in the Department of General Practice, as learning aids and class tests. These were administered to twelve randomly selected groups of students before and after completion of a five week course of teaching. Results show that the composite mean MEQ scores doubled between pre- and post-course tests. The correlation coefficients tabulated do not indicate that the marked improvement in mean scores before and after the course in general practice was influenced to any extent by knowledge acquired in other disciplines. The overall findings clearly establish the value of small group clinical teaching of general practice based on a problem orientated approach to learning. They suggest that the intellectual skills and attitudes required in the 'holistic' approach to problem solving in general practice may differ in some ways from the skills required in specialized areas of medicine. The evaluation justifies the time spent on clarifying the undergraduate educational objectives.     

2种评价方法在护理本科生临床教学实习中的效果比较

目的比较2种不同评价方法在护理本科生临床教学实习中的应用效果。方法选择125名三年级护理本科生,在内、外科护理学课程2周的教学实习过程中,分别应用书写整体护理病历和撰写护理个案论文2种评价方法。教学实习结束后,采用自行设计的问卷进行调查。结果学生认为书写整体护理病历评价教学实习有利于提高整体护理临床思维的能力,撰写护理个案论文有利于培养学生的科研意识,提高其护理信息能力和掌握科研方法。结论 2种评价方法各有特色,应有机结合,为培养学生综合能力提供平台和机会。     

Evaluation of an integrated curriculum using problem-based learning in a clinical environment: the Manchester experience

DESCRIPTION OF COURSE: In 1994, a new problem-based leaning (PBL) curriculum for year 1 medical students was introduced at the University of Manchester. The use of PBL has continued into the clinical clerkships. Year 3 of the curriculum is based entirely in a clinical environment with PBL groups meeting in three teaching hospitals. During this year, all students undertake two integrated 14-week modules with overarching themes. Each week, groups of eight students discuss a trigger problem connected to the relevant theme. The steps the groups use in the PBL process have been amended to encourage students to link their discussion with clinical experience. EVALUATION: At the end of each module, all 309 students were requested to complete an evaluation questionnaire. The response rates were 80% (n=247) and 89% (n=275) for the two core modules. RESULTS: The students have remained 'happy with the way the course is going' (83% at the end of module 2). They were also asked to rate a number of statements on a 5-point Likert scale (5=strongly agree). Concerning PBL, the students remained confident about working in a group (median 4), producing a set of learning objectives (median 4) and linking clinical experience with other knowledge (median 4). However, there were changes over the year. Fewer students agreed at the end of module 2 that 'the working problems were stimulating' (P=0.002) or 'motivated them to learn' (P < 0.001), but the clinical firms were seen as providing more appropriate experience (P=0.01) and being aware of the new curriculum and responding to it (P=0.018). We also surveyed the PBL tutors and had 65 returns from 78 people involved in the 38 PBL groups in year 3. The great majority of these are doctors employed by the National Health service. Virtually all the responders were happy to continue being a tutor (97%) and would recommend it to a colleague (93%). CONCLUSIONS: The evaluation has been positive with PBL having been successfully implemented in a clinical environment. We have identified significant changes over the year, which we need to address as we consolidate the curriculum.     

Communication skill of general practitioners: any room for improvement? how much can it be improved?

OBJECTIVE: To measure any changes in the communication skills of primary care physicians before and after a part-time Diploma course in Family Medicine. SUBJECTS: 79 Hong Kong Chinese doctors (46 of whom were local graduates, with an average of 7 years in general practice). METHODS: Over the 10-month course in 2000-01, participants had 11 2.5-hour lecture/demonstrations in communication skills, 2 sessions of role play practice in groups of 20, self-analysis of a videotaped interview and skills evaluation. A before-after design measured scores in videotaped simulated patient interviews (rated by a research assistant using a structured observation guide, after standardisation by a psychologist) and scores in Objective Structured Clinical Examinations (OSCE) (rated by experienced family physician examiners with standardised checklists). RESULTS: There were wide variations in baseline skills, with scores ranging between 24-78 (out of 100) for video and 18-68 for OSCE, which were related to prior training and inversely associated with years after graduation. Significant improvements occurred in both video (from 53 to 61) and OSCE (from 46 to 56) post-course (P < 0.001). The group in the lowest quartile improved from 36 to 54 for video and from 29 to 48 for OSCE, while those in the second lowest quartile improved from 50 to 61 for video and from 44 to 56 for OSCE (F = 12.2, P < 0.001). Doctors who graduated more than 20 years ago made as much improvement as more recent graduates. CONCLUSIONS: Communication skills can be effectively taught to, and improved among experienced Chinese doctors by a combination of large-class teaching and medium-sized group practice with feedback, and without intensive individual supervision.     

Difficulty and discrimination capacity of examinations estimated on the basis of repeated student failure

This paper examines the difficulty and discrimination capacity of several subjects for problematic students, i.e., those failing repeatedly (re-examined four or more times) in at least one subject. Four hundred and six problematic students were analysed. The difficulty in passing thirty-one mandatory subjects was assessed in two ways:

• 1 on the basis of the attrition rate of the students due to pass the subject,
• 2 on the basis of the percentage of number of failures over the number of examinations.

The discrimination capacity of the same subjects was assessed on the basis of ‘false positive’ and ‘false negative’ results. The result of the evaluation of one subject was considered a false positive if it gave an excellent mark to a problematic student; it was considered a false negative if a student had to be reexamined four or more times before passing, although he had at least one excellent passing mark in one or more subjects. There were 157 excellent marks given to 114 problematic students. The two ways to assess difficulty ranked the thirty-one subjects in a very significantly-similar way. The subjects of the first, second and sixth years of study were considerably more difficult than the other years. A high proportion of false-negative results in a subject did not imply necessarily increased difficulty and vice versa. Thus, only two of the five subjects with the highest proportion of false-negative results belonged to the group of the five most difficult subjects. Also, three of the five subjects with the highest proportion of false-positive results belonged to the group of the five easiest subjects. Finally, only one of the five subjects with the lowest proportion of false (positive plus negative) results belonged to the group of the five most difficult subjects. Examination systems involving oral examinations either alone or in conjunction with written ones were more difficult for the problematic students than those involving purely written examinations, while their discrimination capacity was not significantly different. The discrimination capacity of the subjects involving practical examinations as part of their evaluation system was significantly better than that of those not involving practical examinations. It is concluded that a very permissive examination system presents the problem of repeatedly-failing students. A quasi-open admission system, as in Athens University, associated with a very permissive examination system, leads to a pattern of difficulty, the peaks of which appear, mainly, in the first and last year of studies.     

Attitudes towards brief interventions to reduce smoking and problem drinking behaviour in gynaecological practice

Objective

To assess attitudes towards brief interventions, obstacles and assessment rates for smoking and problem drinking in gynaecological practice, and to evaluate the differences between smoking and problem drinking.

Study design

Cross-sectional survey.

Method

An anonymous mail survey was conducted with all 358 primary care gynaecologists in the state of Schleswig-Holstein, Germany.

Results

Most gynaecologists considered brief interventions for problem drinking to be less important in gynaecological practice than in general (74% vs 64%). Brief interventions were believed to be ineffective, particularly for problem drinking (64% vs 53% for smoking). Gynaecologists felt better prepared to counsel their patients than to assess substance use. Only 35% stated that they assess the smoking status of every patient, and less than 12% stated that they assess the alcohol consumption of every patient. The counselling rate for smoking was high (79%), but problem drinkers were often referred to specialists (counselling rate 36%). The most important obstacles for the implementation of brief interventions were lack of time and poor patient compliance. In addition, for problem drinking, insufficient specialization was a further obstacle.

Conclusion

Although a link was found between primary gynaecological care and tobacco and alcohol use, brief interventions are not yet integrated into gynaecological practice. There are, however, some promising starting points for patients who smoke, as motivation among gynaecologists to conduct brief interventions and counselling is high. The findings underscore the need for increased medical education and information about brief interventions, as well as assessment programmes for gynaecologists.     

Clinical problem-solving by medical students: a cross-sectional and longitudinal analysis

The evolution of clinical reasoning in medical students was studied. A cross-sectional sample consisted of randomly-selected medical students from three classes. Additionally, twenty-two students were observed at yearly intervals from the preclerkship period to the first post-graduate year. Subjects were observed in a clinical examination of a simulated patient, and their thought processes were abstracted from a 'stimulated recall' of the videotaped encounter.
The data were transcribed and coded for computer analysis, yielding several variables characterizing the clinical reasoning process, and four measures of outcome of the encounter. Analysis of variance of differences between students at various educational levels and a doctor criterion group indicated that the majority of the process variables were unrelated to educational level. By contrast, diagnostic and management outcomes were positively related to education. The single process variable which was related to both educational level and outcome was an 'hypothesis aggregate score', a measure of the content of the student's diagnostic hypotheses.
The results of the study indicate that the problem-solving or clinical reasoning process remains relatively constant from medical school entry to practice. This observation has important implications for clinical teaching and evaluation.     

Professional uncertainty and the problem of supplier-induced demand

This paper discusses the puzzling problem of large differences in per capita use of certain common surgical procedures among neighboring populations, which by all available measures are quite similar in need for and access to services. The evidence reviewed here supports the hypothesis that variations occur to a large extent because of differences among physicians in their evaluation of patients (diagnosis) or in their belief in the value of the procedures for meeting patient needs (therapy). This hypothesis, which we call the professional uncertainty hypothesis, is germane to current controversies concerning the nature and extent of supplier influence on the demand for medical services. It is also important because of its implications for health regulatory policy. Our plan is to (1) review the relevance of the hypotheses for the supplier-induced demand controversy; (2) review the epidemiologic evidence on the nature and causes of variation; (3) examine patterns of use of common surgical procedures to illustrate the importance of supplier influence on utilization; and (4) consider some of the implications of the professional uncertainty hypotheses for public policy.     

合肥地区高校教师对现行绩效评价满意度分析

目的 了解高校教师对现行绩效评价满意度现况,探讨高校教师绩效评价满意度的综合影响因素,为提高高校教师绩效评价满意度和改进绩效评价工作提供依据.方法 采取随机抽样的方法,对合肥市4所高校257名教师绩效评价满意度情况进行问卷调查.结果 高校教师绩效评价总体满意度得分为3.13,用自行设计的一般情况调查表和教师绩效评价满意度调查表,满分为5分,属中等水平;高校教师绩效评价满意度的主要影响因素包括:“绩效评价体系及绩效评价在师德、教学和科研的体现”、“评价主体参与度”、“绩效评价结果的应用”“绩效评价的激励作用”、“绩效评价方法及评价结果的反馈沟通”、“绩效评价在学科建设贡献度和人才培养工作方面体现”、“绩效评价在社会服务工作方面的体现”、“绩效评价工作内容和信息的了解”;不同任教学科、职称、年龄的高校教师绩效评价满意度的差异有统计学意义(均有P＜0.05).结论 有必要针对相关因素采取改进措施,以提高高校教师绩效评价满意度,促进教师和学校的良好发展.