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Biomedical subjects

G R Norman

Publications and source records attributed to G R Norman.

At least 19 recordsLinked to original sources
PubMed2001

Establishing the minimal number of items for a responsive, valid, health-related quality of life instrument.

Reducing the number of items in a health-related quality of life instrument will enhance efficiency. However, it is important to maintain measurement properties. We determined the effect of reducing items from each domain (dyspnea, fatigue, emotion and mastery) of the 20-item Chronic Respiratory Questionnaire (CRQ). Three randomized trials of respiratory rehabilitation provided data. We removed items one at a time from each domain in three orders: by item impact, item responsiveness, and at random. Responsiveness, test-retest reliability and construct validity were evaluated at each step. Responsiveness and reliability, evaluated by intraclass correlation coefficients (ICC), were reduced marginally as the number of items was reduced to two items per domain. The deterioration was greatest when reducing from two items to one. To detect a particular effect, sample size would increase by about 10% when reducing the number of items in a domain to 2. Construct validity showed a more marked deterioration. Reducing to two items per domain would maintain responsiveness and reliability of the CRQ at an acceptable level, with a trade-off of reduced construct validity and increase in sample size requirements.

Factor Analysis, Statistical↗
PubMed2001

Knowledge and practices regarding tuberculosis: a survey of final-year medical students from Canada, India and Uganda.

CONTEXT: Tuberculosis is one of the most common infectious diseases worldwide and is responsible for the largest number of deaths from a single infectious cause. OBJECTIVE: The objective of this study was to compare the knowledge of and practices regarding tuberculosis in final-year medical students at schools from endemic and non-endemic areas. SUBJECTS: Final-year medical students at McMaster University in Canada, the Christian Medical College in India, and Makerere University in Uganda. METHODS: A questionnaire consisting of 20 multiple-choice questions assessing knowledge, practices, and exposure. A total knowledge score (maximum=13) and a total practice score (maximum=5) were created for each study site. RESULTS: 160 questionnaires were returned; the response rate was 68.4% (65/95) for McMaster University, 39.7% (23/58) for the Christian Medical College and 78.3% (72/92) for Makerere University. Students from Makerere University had the highest knowledge scores but differences were non-significant after adjustment for patient exposure and curriculum time (F(2,153)= 1.80, P=0.16). Differences in practice scores, however, remained significant after adjusting for curriculum time and patient exposure (F(2,153)=5.14, P=0.006). Knowledge score (F(1,156)=5.05, P=0.02), patient exposure (F(1,153)=9.11, P=0.003), and curriculum time and patient exposure (F(2,153)=5.14, P=0.006) were statistically significant positive predictors of the total practice score. CONCLUSIONS: This study demonstrated significant differences in undergraduate exposure to tuberculosis, total knowledge, and practice competency at three medical schools in Canada, India, and Uganda. In general, the knowledge base and practice competency of all three graduating classes was adequate.

Analysis of Variance↗
PubMed2001

Relation of distribution- and anchor-based approaches in interpretation of changes in health-related quality of life.

BACKGROUND: Approaches to interpretation of quality of life changes in clinical trials have fallen into two camps: those that rely on the distribution of changes and the Effect Size (ES), and those that use some external anchor, such as patient judgments of change, which is then used to compute a Minimally Important Difference (MID), the proportion benefiting from treatment, p(B), and the Number Needed to Treat (NNT). OBJECTIVE: To examine the relationship between the ES and p(B), and the impact of the MID on this relationship. METHODS: Simulation was used based on a normal distribution to compute the proportion of patients benefiting in both parallel group and crossover designs, for various values of the ES and the MID. The agreement of the simulation with empirical data from four studies of asthma and respiratory disease was assessed. The effect of skewness in the distributions of change scores on the relationship between ES and p(B) was also examined. RESULTS: The simulation showed a near-linear relationship between ES and p(B), which was nearly independent of the value of the MID. Agreement of the simulation with the empirical data were excellent. Although the curves differed for crossover and parallel group designs, the general form was similar. Introducing moderate skew into the distributions had minimal impact on the relationship. CONCLUSIONS: The proportion of patients who will benefit from treatment can be directly estimated from the ES, and is nearly independent of the choice of MID. Effect size and anchor based approaches provide equivalent information in this situation.

Chronic Disease↗
PubMed2001

Comparison of the standard gamble, rating scale, AQLQ and SF-36 for measuring quality of life in asthma.

With interest in health economics growing, there is a demand for valid methods for measuring health-related quality of life (HRQL) in asthma using utilities. The aims of this study were to develop disease-specific versions of the standard gamble and rating scale, to compare their measurement properties with those of the Asthma Quality of Life Questionnaire (AQLQ) and the Medical Outcomes Survey Short-Form 36 (SF-36), as well as to determine their validity for assessing asthma-specific quality of life. Forty adults with symptomatic asthma participated in a 9-week observational study. Participants completed the standard gamble, rating scale, AQLQ, SF-36 and other measures of clinical asthma status at baseline and after 1, 5 and 9 weeks. In patients whose asthma was stable between assessments, reliability was good for the rating scale (intraclass correlation coefficient (ICC)=0.89) and the AQLQ (ICC=0.95) but more modest for the SF-36 mental score (ICC=0.68), SF-36 physical score (ICC=0.65) and standard gamble (ICC=0.59). The responsiveness index was highest in the AQLQ (1.35), followed by the rating scale (0.74), the physical score of the SF-36 (0.61) and the standard gamble (0.31). Construct validity (correlation with other indices of health status) was strongest for the AQLQ and the rating scale. In conclusion, both the disease-specific rating scale and the Asthma Quality of Life Questionnaire have strong measurement properties for measuring asthma-specific quality of life; the Short-Form 36 health survey physical summary score has more modest properties. Although the disease-specific standard gamble has acceptable discriminative properties, its evaluative properties are too inadequate for it to be used in cost/utility analyses. Poor correlation between the standard gamble and the rating scale indicates that utilities cannot be derived from rating scale data.

Activities of Daily Living↗
PubMed2001

Coordination of analytic and similarity-based processing strategies and expertise in dermatological diagnosis.

BACKGROUND: Medical diagnosis may be thought of as a categorization task. Research and theory in psychology as well as medical decision making indicate at least 2 processes by which this categorization task may be accomplished: (a) analytic processing, in which one makes explicit use of clinical features to reach a diagnosis, and (b) similarity-based processing, in which one makes use of past exemplars to reach a clinical diagnosis. Recent research indicates that these 2 processes are complementary. PURPOSE: We investigate the coordination of analytic and similarity-based processes in clinical decision making to examine if the relative reliance on these 2 processes is (a) amenable to instruction and (b) dependent on level of clinical experience. METHODS: The reliance of these 2 processes was indexed by the performance of 12 preclinical medical students on cases dichotomized as typical and atypical (analytic processing) and on cases dichotomized as similar or dissimilar to cases seen previously in a training phase (similarity-based processing). RESULTS: The results indicated that both processes are operative. Of particular interest was that preclinical medical students enhanced their performance by adopting a similarity-based strategy. This was especially so for atypical cases. These results are in contrast to residents, who enhanced their performance by adopting an analytic strategy. CONCLUSIONS: The relative reliance on analytic and similarity-based processes is amenable to instruction and dependent on expertise.

Clinical Competence↗
PubMed2000

The alternating-sequence design (or multiple-period crossover) trial for evaluating treatment efficacy in infertility.

OBJECTIVE: To determine whether a constant-sequence or an alternating-sequence design is better for the evaluation of infertility treatment efficacy when multiple cycles of treatment are undertaken. DESIGN: A simulation exercise using analytical methods. SETTING: University medical center. PATIENT(S): A hypothetical, heterogeneous population of infertile patients participating in a randomized trial comparing an experimental treatment, with effectiveness of 2.0, to no treatment. INTERVENTION(S): Comparison of a constant-sequence design in which the subject receives the same intervention or the alternating-sequence design in which experimental and control treatments are crossed over after each successive cycle. MAIN OUTCOME MEASURE(S): Relative risks of pregnancy per cycle and overall after a maximum of five cycles of treatment. RESULT(S): With both designs, the pregnancy rates in experimental and control groups showed a consistent decrease with each successive cycle. The overall effectiveness in the constant-sequence design was underestimated at 1.83, whereas in the alternating-sequence design it was overestimated at 2.06. However, by restricting the analysis in the latter design only to the odd-numbered cycles, the relative risk was precisely correct at 2.00. CONCLUSION(S): When multiple cycles of treatment are undertaken to evaluate the efficacy of infertility therapy, the alternating-sequence design with restriction of the analysis to only the odd-numbered treatment cycles provides an unbiased estimation of the treatment effect.

Clinical Trials as Topic↗
PubMed2000

Effectiveness of problem-based learning curricula: theory, practice and paper darts.

In a recent review article, Colliver concluded that there was no convincing evidence that problem-based learning was more effective than conventional methods. He then went on to lay part of the blame on cognitive psychology, claiming that 'the theory is weak, its theoretical concepts are imprecise. the basic research is contrived and ad hoc'. This paper challenges these claims and presents evidence that (a) cognitive research is not contrived and irrelevant, (b) curriculum level interventions are doomed to fail and (c) education needs more theory-based research.

Clinical Competence↗
PubMed2000

On the difficulty of noticing obvious features in patient appearance.

Medical students and experts were given head-and-shoulder photographs of patients, each showing a key feature of the patient's problem. Three quarters of these pictures were taken from textbooks. Noticing these supposedly obvious features was difficult and strongly influenced by contextual factors. Both experts and students gained about 20% in diagnostic accuracy by having the key features verbally described for them, although these were clearly visible on the photographs. Conversely, both experts and students reported seeing more of these features when the correct diagnosis was suggested to them. This facilitation resulted from an increase in sensitivity to depicted features, rather than a response bias. The properties of these features that allow such failures of noticing are discussed.

Adult↗
PubMed2000

Assessing the measurement properties of a clinical reasoning exercise.

BACKGROUND: A challenge for Problem-Based Learning (PBL) schools is to introduce reliable, valid, and cost-effective testing methods into the curriculum in such a way as to maximize the potential benefits of PBL while avoiding problems associated with assessment techniques like multiple-choice question, or MCQ, tests. PURPOSE: We document the continued development of an exam that was designed to satisfy the demands of both PBL and the scientific principles of measurement. METHODS: A total of 102 medical students wrote a clinical reasoning exercise (CRE) as a requirement for two consecutive units of instruction. Each CRE consisted of a series of 18 short clinical problems designed to assess a student's knowledge of the mechanism of diseases that were covered in three subunits located within each unit. Responses were scored by a student's tutor and a 2nd crossover tutor. RESULTS: Generalizability coefficients for raters, subunits, and individual problems were low, but the reliability of the overall test scores and the reliability of the scores across 2 units of instruction were high. Subsequent analyses found that the crossover tutor's ratings were lower than the ratings provided by one's own tutor, and the CRE correlated with the biology component of a progress test. CONCLUSION: The magnitude of the generalizability coefficients demonstrates that the CRE is capable of detecting differences in reasoning across knowledge domains and is therefore a useful evaluation tool.

Education, Medical, Undergraduate↗
PubMed1999

Examining the assumptions of evidence-based medicine.

Evidence-based medicine (EBM) has had enormous impact on clinical medicine, attracting both converts and detractors. The basic premise, that clinical decisions should be made on evidence which is as sound as possible, appears unassailable. Why, then, has the idea stimulated such controversy? In this article, I examine six assumptions of EBM, and point out how these assumptions are frequently open to challenge. Finally, I make specific recommendations for future activities to ensure that the strategy achieves an appropriate role in health care decision-making. These include: (1) conducting research to establish the effectiveness of EBM; (2) incorporating (as they apparently are) more holistic perspectives on the nature of evidence; (3) moving (as they are) toward the use of expert reviews and away from a focus on the skilled individual practitioner; (4) examining the literature on continuing education to devise more appropriate dissemination strategies, including, specifically, educational influentials; and (5) making specific attempts at conciliation and seeking common ground with other schools of thought.

Decision Making↗
PubMed1999

Impact of a clinical scenario on accuracy of electrocardiogram interpretation.

To examine the effect of clinical history on the electrocardiogram (ECG) interpretation skills of physicians with different levels of expertise, we randomly allocated to an ECG test package 30 final-year medical students, 15 second-year internal medicine residents, and 15 university cardiologists at university-affiliated teaching hospitals. All participants interpreted the same set of 10 ECGs. Each ECG was accompanied by a brief clinical history suggestive of the correct ECG diagnosis, or the most plausible alternative diagnosis, or no history. Provision of a correct history improved accuracy by 4% to 12% compared with no history, depending on level of training. Conversely, a misleading history compared with no history reduced accuracy by 5% for cardiologists, 25% for residents, and 19% for students. Clinical history also affected the participants' frequencies of listing ECG features consistent with the correct diagnosis and features consistent with the alternative diagnosis (all p values < .05). For physicians at all levels of expertise, clinical history has an influence on ECG diagnostic accuracy, both improving accuracy when the history suggests the correct diagnosis, and reducing accuracy when the history suggests an alternative diagnosis.

Adult↗
PubMed1999

Effect of the framing of questionnaire items regarding satisfaction with training on residents' responses.

PURPOSE: To determine whether framing questions positively or negatively influences residents' apparent satisfaction with their training. METHOD: In 1993-94, 276 residents at five Canadian internal medicine residency programs responded to 53 Likert-scale items designed to determine sources of the residents' satisfaction and stress. Two versions of the questionnaire were randomly distributed: one in which half the items were stated positively and the other half negatively, the other version in which the items were stated in the opposite way. RESULTS: The residents scored 43 of the 53 items higher when stated positively and scored ten higher when stated negatively (p < .0001). When analyzed using an analysis-of-variance model, the effect of positive versus negative framing was highly significant (F = 129.81, p < .0001). While the interaction between item and framing was also significant, the effect was much less strong (F = 5.56, p < .0001). On a scale where 1 represented the lowest possible level of satisfaction and 7 the highest, the mean score of the positively stated items was 4.1 and that of the negatively stated items, 3.8, an effect of 0.3. CONCLUSIONS: These results suggest a significant "response acquiescence bias." To minimize this bias, questionnaires assessing attitudes toward educational programs should include a mix of positively and negatively stated items.

Adult↗
PubMed1999

The adult learner: a mythical species.

Adult learning theory, first described by Malcolm Knowles in the early 1970s, is based on a number of apparently self-evident axioms about how adults learn. The fundamental assumptions remain largely untested, and a critical analysis suggests that they may be largely a product of the environment in which adults find themselves rather than of any innate differences between adults and children. What evidence does exist suggests that one critical component of adult learning, self-assessment, is not easy. Further, while students can learn the skills to learn on their own (i.e., can acquire self-directed learning skills), this does not translate into greater competence, in either the short or long term. Uncritical reliance on the principles of adult learning may have detrimental consequences, particularly in the domain of maintenance of competence.

Adult↗