ASSESSING CLINICAL COMPETENCE: RECOGNITION OF CASE DESCRIPTIONS OF RHEUMATIC DISEASES BY GENERAL PRACTITIONERS

The objective of this study was to detect strengths and weaknessesin the diagnosis of rheumatic diseases by general practitionersin order to set up post-graduate training accordingly and toassess whether open-ended questions give results comparablewith multiple choice-type questions. Fifty-one general practitionerswere given eight written cases: rheumatoidarthritis (RA), ankylosingspondylitis (AS), reactive arthritis, psoriatic arthritis (PsA),systemic lupus erythematosus (SLE), gout, polymyalgia rheumaticaand pseudogout. Only signs and symptoms were provided. All caseswere derived from realpatients with a definite diagnosis. Eachcase was presented in both types of question formats. The caseswere also presented to 23 rheumatologists. We found that inthe open-ended question format 57.1% of the general practitionersgave the correct answers. Cases of RA, AS, gout and PsA werecorrectly diagnosed by >70% of the general practitioners.Cases of polymyalgia rheumatica and reactive arthritis werecorrectly diagnosed by 55 and 39% of the general practitioners,respectively. The cases of pseudogout and SLE were correctlydiagnosed by less than 11% of the general practitioners. Fifty-twoper cent of the general practitioners gave the correct answersto the multiple choice-type questions. There was no statisticaldifference in the correct answers between the open-ended questionsand the multiple choice-type questions. We concluded that assuminggeneralization of the results, training of general practitionersshould include polymyalgia rheumatica, reactive arthritis, SLEand pseudogout. KEY WORDS: Clinical competence, Rheumatic diseases, General practitioners, Quality assurance, Health care     

Reliability and feasibility of measuring medical interviewing skills: the revised Maastricht History-Taking and Advice Checklist

Medical interviewing skills are integral to good medical care. In order to measure these skills an instrument has been developed, called the Maastricht History-Taking and Advice Checklist (MAAS). It has been studied with regard to interrater reliability and validity. In this study a revised version of the MAAS (MAAS-R), a check-list of concrete interview behaviour, has been investigated concerning feasibility and reliability for examination purposes. Audio-recordings were obtained of 24 doctors, each interviewing eight different standardized patients. The recordings were independently scored by three general practitioners trained in using the MAAS-R. The results of generalizability analysis, considering the influences of doctors, cases and raters, are encouraging. In order to overcome case-specificity feasible and reliable measurement can be accomplished with 8-10 cases in 2-21/2 hours of testing time, each case being scored by a different rater. Reliability improves considerably if assessment is restricted to basic interviewing skills.     

Dapsone versus topical immunotherapy in alopecia areata

Twenty-seven patients with severe alopecia areata were treated with dapsone. The results of a mean treatment duration of 10±0.5 months are reported, and compared with the results of long-term topical immunotherapy obtained previously at the same institute. The efficacy of dapsone proved to be markedly inferior to that of topical immunotherapy. The percentage of patients showing regrowth of hair during treatment with dapsone was comparable with the occurrence of spontaneous regrowth of hair reported in the literature.     

Pitfalls in the pursuit of objectivity: issues of reliability

Objectivity has been one of the hallmarks in the assessment of clinical competence in recent decades. A consistent shift can be noticed in which subjective measures are being replaced by objective measurement methods. In the transition from subjective to objective methods trade-offs are involved, both in the effort expended and in the range of behaviours assessed. The issue of the presumed superiority of objective measures is addressed in two successive papers. In this paper a distinction is made between objectivity as a goal of measurement, marked by freedom of subjective influences in general, and objectivity as a set of strategies designed to reduce measurement error. The latter has been termed objectification. The central claim of this paper is that these two approaches to assessment do not necessarily coincide. By reviewing a number of studies comparing subjective and objectified measurement methods, the claim of the supremacy of the latter with respect to reliability is discussed. The results of these studies indicate that objectified methods do not inherently provide more reliable scores. Objectified methods may even provide unwanted outcomes, such as negative effects on study behaviour and triviality of the content being measured. The latter issues, related to validity, efficiency and acceptability, are discussed in a second paper.     

A written test as an alternative to performance testing

Performance tests are logistically complex and time consuming. To reach adequate reliability long tests are imperative. Additionally, they are very difficult to adapt to the individual learning paths of students, which is necessary in problem-based learning. This study investigates a written alternative to performance-based tests. A Knowledge Test of Skills (KTS) was developed and administered to 380 subjects of various educational levels, including both first-year students and recently graduated doctors. By comparing KTS scores with scores on performance tests strong convergent validity was demonstrated. The KTS failed discriminant validity when compared with a general medical knowledge test. Also the identification of sub-tests discriminating between behavioural and cognitive aspects was not successful. This was due to the interdependence of the constructs measured. The KTS was able to demonstrate differences in ability level and showed subtle changes in response patterns over items, indicating construct validity. It was concluded that the KTS is a valid instrument for predicting performance scores and could very well be applied as supplementary information to performance testing. The relative ease of construction and efficiency makes the KTS a suitable substitute instrument for research purposes. The study also showed that in higher ability levels the concepts which were meant to be measured were highly related, giving evidence to the general factor theory of competence. However, it appeared that this general factor was originally non-existent in first-year students and that these competencies integrate as the educational process develops.     

The epidermis of chronic idiopathic lichen planus during topical treatment with the vitamin D3 analogue KH 1060

A parallel-group, double-blind, randomised study was performed to establish the effect of the vitamin D₃ analogue KH 1060, in an ointment versus vehicle only, on the epidermal cell characteristics of chronic idiopathic lichen planus; KH 1060 also has marked immunosuppressive activity.   A group of 10 patients were treated for 8 weeks with either KH 1060 ointment or vehicle only. In addition to the assessment of clinical scores, keratotome biopsies were taken before and after 8 weeks' treatment. Epidermal cell suspensions were prepared with trypsin and the suspensions incubated with TO-PRO-3 (DNA marker), RKSE 60 (marker for keratin 10-positive cells) and antivimentin (marker for all non-keratinocytes). In nine of the 10 patients, keratotome biopsies were obtained both before and after 8 weeks treatment. The vehicle alone had no significant effect on the clinical severity scores or epidermal cell characteristics. In contrast, the KH 1060 ointment resulted in a statistically significant reduction in the percentage of cells in S- and G₂M phase and the percentage of vimentin-positive cells, but it did not affect the percentage of keratin 10-positive cells.     

Epidermal differentiation characteristics of the psoriatic plaque during short contact treatment with dithranol cream

Dithranol has been used successfully in the treatment of psoriasis for more than 75 years, and much in vitro anti in vivo research has been done on the elucidation of the mode of action of this potent and safe antipsoriatic therapy. In vivo research has research major effects of dithranol on epidermal proliferation and inflammation- Information on the in vivo effects on epidermal differentiation is limited. Therefore, the dynamics of a set of differentiation markers (keratin 16, filaggrin, keratinocyte transglutaminase, involucrin) and markers for proliferation and inflammation (Ki-67, T lymphocytes, polymorphonuclear leucocytes) were studied in skin biopsies of six patients with psoriasis during 4 weeks of dithranol therapy. The treatment regimen involved a short contact protocol at our out-patient day treatment centre with an easily washed off cream. Treatment resulted in a decrease of the PASI score of 48° in 4 weeks. Immunohistochemically, a major decrease of keratin 16 content and virtually complete restoration of the filaggrin positive cell layer were seen. These changes proved to be significant by comparison of the markers over the group of six patients. Although many other topical treatments for psoriasis (occlusive therapy and vitamin D₃ analogues) result in a prominent reduction in the amount of transglutaminase and involucrin positive cell layers, the effect of dirhranol on these markers is minimal.