Does studying for an objective structured clinical examination make a difference?

PURPOSE: This study examines the extent to which second-year medical students studied for an objective structured clinical examination (OSCE), how they studied, and the impact of self-reported studying on OSCE performance. METHOD: One class of 113 medical students completed an end-of-second-year OSCE, held on two consecutive evenings. The OSCE was comprised of eight stations, each of which was of 20 minutes' duration. The OSCE was formative: students received performance feedback but were not graded. Prior to the OSCE, students completed a brief survey regarding their preparation for the OSCE and their perceptions of confidence, anxiety and preparedness. Only 78 students returned surveys with names, comprising the data for these analyses. RESULTS: Mean studying time was 3.3 h, ranging from 0 to 19 h. Studying time was positively associated with age and negatively associated with basic science examination scores. The most study time was dedicated to reviewing the physical examination textbook, class notes and supplemental course readings. The breadth of study strategies increased as more time was spent in OSCE preparation. OSCE performance was related to study time and to achievement on pre-clinical basic science examinations. DISCUSSION: The students whose performance was above average seemed to be the talented students whose records indicated a history of academic success. The amount of time they reported for OSCE preparation was comparable to that reported by students with below average performance. It appears that prior academic performance rather than preparatory studying time is a better predictor of OSCE outcomes.     

Does the gender of the standardised patient influence candidate performance in an objective structured clinical examination?

Context  The objective structured clinical examination (OSCE) requires the use of standardised patients (SPs). Recruitment of SPs can be challenging and factors assumed to be neutral may vary between SPs. On stations that are considered gender-neutral, either male or female SPs may be used. This may lead to an increase in measurement error. Prior studies on SP gender have often confounded gender with case.
Objective  The objective of this study was to assess whether a variation in SP gender on the same case resulted in a systematic difference in student scores.
Methods  At the University of Ottawa, 140 Year 3 medical students participated in a 10-station OSCE. Two physical examination stations were selected for study because they were perceived to be 'gender-neutral'. One station involved the physical examination of the back and the other of the lymphatic system. On each of the study stations, male and female SPs were randomly allocated.
Results  There was no difference in mean scores on the back examination station for students with female (6.96/10.00) versus male (7.04/10.00) SPs ( P  = 0.713). However, scores on the lymphatic system examination station showed a significant difference, favouring students with female (8.30/10.00) versus male (7.41/10.00) SPs ( P  < 0.001). Results were not dependent on student gender.
Conclusions  The gender of the SP may significantly affect student performance in an undergraduate OSCE in a manner that appears to be unrelated to student gender. It would be prudent to use the same SP gender for the same case, even on seemingly gender-neutral stations.     

Can context justify an ethical double standard for clinical research in developing countries?

Background  

The design of clinical research deserves special caution so as to safeguard the rights of participating individuals. While the international community has agreed on ethical standards for the design of research, these frameworks still remain open to interpretation, revision and debate. Recently a breach in the consensus of how to apply these ethical standards to research in developing countries has occurred, notably beginning with the 1994 placebo-controlled trials to reduce maternal to child transmission of HIV-1 in Africa, Asia and the Caribbean. The design of these trials sparked intense debate with the inclusion of a placebo-control group despite the existence of a 'gold standard' and trial supporters grounded their justifications of the trial design on the context of scarcity in resource-poor settings.     

Can electronic routine data act as a surrogate for patient-assessed outcome measures?

OBJECTIVES: There has been a rapid growth in the use of patient-assessed outcomes (PAOs) that are measured in the assessment of health technologies. The process of collection of such measures can be costly, and there may be problems associated with the ability of the patient to complete them. The use of electronically stored routine data may reduce costs and overcome the problems associated with patient completion. The feasibility of using routine data surrogates for the UK Inflammatory Bowel Disease Questionnaire (UKIBDQ) and the Short Form 36 (SF-36) was examined. METHODS: Clinical terms and codes for the UKIBDQ and SF-36 questions were identified, and data from electronic routine sources were sought on patients participating in a randomized controlled trial. The presence or absence of relevant symptoms was used to generate surrogate scores, which were compared with the original scores. RESULTS: Most questions in the UKIBDQ and SF-36 were codable but only one third of the terms were recorded routinely in electronic form. The surrogate total IBDQ score had reasonable reliability (Kuder-Richardson coefficient = 0.51), but this reliability could not be determined for the SF-36. Intraclass correlations between routine and designed data were poor to weak. CONCLUSIONS: Although electronic routine data sources had the capacity to develop surrogate measures for patient assessed outcomes, there was evidence of wide underutilization of coding systems leading to an underreporting of symptoms. This finding is consistent with previous literature where only poor correlations were illustrated between patient assessed outcomes and surrogate scoring of symptoms.     

Do patients have an obligation to participate in student teaching?

Context  Patients may participate in teaching in many ways, in different settings and with different degrees of expert supervision. The majority of patients are generally very willing to participate in teaching. At times, however, patients may decline to see students because they are too sick, wish to maintain their privacy, prefer to have more expert care, or simply wish to have no involvement with students. This raises the question as to whether patients have any obligation to participate in education.
Methods  A number of arguments are advanced to justify the claim that patients have an obligation to participate in student teaching. These include: that patients should participate in training for the benefit of others if they wish to benefit from the care of those who have learnt from others; that, without patient participation in teaching, the entire health system would collapse; that participation in education provides a benefit over and above the provision of individual care; that, as we all benefit from the presence of a functioning health system, we should all be prepared to contribute to it, and that patients should 'pay' for free public health care by participating in teaching.
Conclusions  None of the arguments that patients have an obligation to participate in medical education are convincing. We believe that patients participate in training largely out of altruism rather than obligation. Where possible, sick patients should be substituted for by healthy patients or simulations.     

Can subjective and objective socioeconomic status explain minority health disparities in Israel?

Disparities in health exist between the three main population groups in Israel, non-immigrant Jews, immigrants from the former Soviet Union (arriving in Israel since 1990) and Arabs. This study examines the relationship between health and socioeconomic status in this multicultural population and assesses to what extent subjective and objective socioeconomic measures may explain the disparities in health. A random cross sectional telephone survey of 1004 Israelis aged 35–65 was performed. The questionnaire measured physical and mental health-related quality of life using the Short Form 12. Information regarding subjective socioeconomic status (SSS) and objective socioeconomic status (SES) was collected.Arabs and immigrant women from the former Soviet Union had worse physical health compared to non-immigrant Jews. Immigrant and Arab men and women had worse mental health compared to non-immigrant Jews. Multivariable log-linear regression analysis adjusting for age, SSS or SES explained the disparities in physical health between Arab and non-immigrant Jewish men. However, SSS and SES did not explain the disparities in physical health between the three groups of women. The disparities in mental health between immigrants and non-immigrant Jews can be explained by SSS for both men and women, whereas the disparities between Arabs and Jews can be explained by objective SES only among women. Employed men reported better physical and mental health. Part of the disparities in mental health in Israel can be attributed to differences in SSS and SES in the different groups. However, there is a need to identify additional factors that may add to the disparities in both physical and mental health. The disparities due to socioeconomic status vary by health measure and population group.     

Does cholesterol act as a protector of cholinergic projections in Alzheimer's disease?

The relationship between Alzheimer's disease (AD) and progressive degeneration of the forebrain cholinergic system is very well established, whereas mechanisms linking this disease with cholesterol, apolipoprotein E (apoE) phenotype, and amyloid precursor protein (APP) metabolism have not been fully elucidated even though there is a plethora of publications separately on each of these issues. The intention of this hypothesis is to unify knowledge coming from all of these areas. It is based on an assumption that the process of APP hypermetabolism is a neuroprotective response for age-related cholinergic deterioration. In some individuals this initially positive process becomes highly overregulated by genetic or/and epigenetic risk factors and after many years of accumulations lead eventually to AD. I hypothesise that neuroprotective role of APP-hypermetabolism might be related to enrichment of neuronal membranes (lipid rafts in particular) in cholesterol in order to compensate for decrease in presynaptic cholinergic transmission and/or AD-related decrease in cholesterol levels. The above is consistent with findings indicating that activity of both muscarinic and nicotinic cholinergic receptors is correlated in a positive manner with cholesterol plasmalemmal content. Briefly – APP metabolism together with transport of cholesterol in apoE containing lipoproteins seem to play a key role in mobilising cholesterol into neuronal membranes.     

Malnutrition as an independent predictor of clinical outcome in critically ill children

ObjectiveTo determine the nutritional status of a cohort of children admitted to a pediatric intensive care unit (ICU) and to assess the effect of malnutrition as an independent risk factor affecting outcome in this patient group.MethodsIn a prospective cohort study, 385 children admitted to the ICU of a teaching hospital over a 2-y period were assessed for nutritional status at admission and clinical outcome. The outcome variables were 30-d mortality, length of ICU stay, and length of mechanical ventilation. Potential exposure variables were gender, age, diagnosis (clinical versus surgical), septic shock, malnutrition, and scores on the Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction. Nutritional status was determined using z scores of weight for age, height for age, and body mass index, based on the World Health Organization child growth standards. Patients with z score < ?2 of anthropometric indexes were considered malnourished.Results175 patients (45.5%) were malnourished on admission. Sixteen patients of the malnourished group (9.14%) and 25 patients (11.9%) of the non-malnourished group died. Malnutrition was associated with greater length of mechanical ventilation and length of ICU stay, but not with mortality on univariate analysis. Malnutrition was associated with greater length of ventilation on the multiple logistic regression model (OR 1.76, 95%; CI 1.08-2.88; P = 0.024).ConclusionMalnutrition is common among children admitted to an ICU. This factor was not a predictor of mortality but showed independent association with length of mechanical ventilation.     

Can physician examiners overcome their first impression when examinee performance changes?

There is an increasing focus on factors that influence the variability of rater-based judgments. First impressions are one such factor. First impressions are judgments about people that are made quickly and are based on little information. Under some circumstances, these judgments can be predictive of subsequent decisions. A concern for both examinees and test administrators is whether the relationship remains stable when the performance of the examinee changes. That is, once a first impression is formed, to what degree will an examiner be willing to modify it? The purpose of this study is to determine the degree that first impressions influence final ratings when the performance of examinees changes within the context of an objective structured clinical examination (OSCE). Physician examiners (n?=?29) viewed seven videos of examinees (i.e., actors) performing a physical exam on a single OSCE station. They rated the examinees’ clinical abilities on a six-point global rating scale after 60 s (first impression or FIGR). They then observed the examinee for the remainder of the station and provided a final global rating (GRS). For three of the videos, the examinees’ performance remained consistent throughout the videos. For two videos, examinee performance changed from initially strong to weak and for two videos, performance changed from initially weak to strong. The mean FIGR rating for the Consistent condition (M?=?4.80) and the Strong to Weak condition (M?=?4.87) were higher compared to their respective GRS ratings (M?=?3.93, M?=?2.73) with a greater decline for the Strong to Weak condition. The mean FIGR rating for the Weak to Strong condition was lower (3.60) than the corresponding mean GRS (4.81). This pattern of findings suggests that raters were willing to change their judgments based on examinee performance. Future work should explore the impact of making a first impression judgment explicit versus implicit and the role of context on the relationship between a first impression and a subsequent judgment.     

Can brief workshops improve clinical instruction?

CONTEXT: The impact of faculty development activities aimed at improving the teaching skills of clinical instructors requires elucidation. Since 2003, all instructors at our school of medicine have been required to undertake a brief workshop in basic clinical instructional skills as a prerequisite for promotion and tenure. The impact of this has, so far, remained unknown.OBJECTIVE: This study aimed to examine to what extent participation in a brief workshop can improve clinical instructors' performance in the long run, and which particular dimensions of performance are improved.METHODS: The study included a sample of 149 faculty members who undertook a required workshop in basic instructional skills. The teaching performance of these faculty members was measured by student feedback a year after the workshop. The study used pre- and post-test design, with a comparison group of 121 faculty members.RESULTS: Student ratings for 5 dimensions of clinical instruction increased significantly, but only for the study group who had participated in a workshop. The comparison group's ratings were unchanged. The highest improvement in the instructors' performance related to availability of teachers to students.CONCLUSIONS: The study supports previous findings about the added value gained by longterm improvement of instructional skills after participation in even a brief workshop. The meaningful improvement in instructor availability to students is associated with the workshops' emphasis on a learner-centred approach and the need to provide continuous feedback.     

Talking about breast symmetry in the breast cancer clinic: What can we learn from an examination of clinical interaction?

BackgroundBreast asymmetry is a common post‐operative outcome for women with breast cancer. Quality of cosmetic result is viewed clinically as a critical endpoint of surgery. However, research suggests that aesthetic standards governing breast reconstruction can be unrealistic and may problematically enforce feminine appearance norms. The aim of reconstructive procedures is to help women live well with and beyond breast cancer. Therefore, understanding how patients and clinicians talk about surgical outcomes is important. However, we lack evidence about such discussions.ObjectiveTo examine clinical communication about breast symmetry in real‐time consultations in a breast cancer clinic.DesignSeventy‐three consultations between 16 clinicians and 47 patients were video‐recorded, transcribed and analysed using conversation analysis.ResultsIn most cases, patients do considerable interactional work to persuade clinicians of the validity of their concerns regarding breast asymmetry, and clinicians legitimize these concerns, aligning with patients. In a significant minority of cases, patients appear more accepting of their treatment outcome, but clinicians prioritize symmetry or treat symmetry with the presence of breast tissue as normative, generating misalignment between clinician and patient.ConclusionCurrent clinical communication guidelines and practices may inadvertently reinforce culturally normative assumptions regarding the desirability of full, symmetrical breasts that are not held by all women. Clinicians and medical educators may benefit from detailed engagement with recordings of clinical communication like those analysed here, to reflect on which communicative practices may work best to attend to a patient''s individual stance on breast symmetry, and optimize doctor‐patient alignment.