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Biomedical subjects

J W Feightner

Publications and source records attributed to J W Feightner.

31 records · Page 2Linked to original sources
PubMed1983

Difficulties in clinical skills evaluation.

A case-specific method of evaluating clinical skills is presented. The instrument is described together with its evaluation based on results from ninety-two medical students. The method involves direct observation, by pairs of teachers, of student encounters with simulated patients. The purpose of this paper is to explore the methodology of assessing clinical competence. Three aspects of this are addressed: reliability between teachers acting as observers, and the relationship of both observations of process measures and self-assessments with the students' understanding of the patient. Three aspects of clinical skills were evaluated; interviewing, problem orientation and physical examination. The results showed the observers to be highly reliable in observing physical examination but to have a wide range of reliability across cases in their observations of the other aspects of clinical skill. There was no correlation between both teachers' observations and the students' self-assessments with the students' understanding of the patient. This is a worrying finding. The implications of this study are that evaluation of the process of clinical skills is difficult methodologically and, added to which, it is not clear what relevance these observations have to clinical competence. Rather than effort being devoted to refining instruments to measure the process of clinical skills it would seem preferable to devote energy to assessing students' abilities in diagnosis and management, at least until we understand what observations of clinical skills are measuring.

Clinical Competence↗
PubMed1982

A comparison of resident performance on real and simulated patients.

Although simulated patients have been increasingly used in medical education, the validity of this procedure--that is, the relationship between performance on a simulated patient and performance with a real patient presenting a similar clinical problem--has not been adequately addressed. The study on which this article is based was an attempt to examine this question. Four actual patients with chronic stable findings were used in the study; four simulated patients were then programmed to present the same problem. A sample of 10 residents in family and internal medicine interviewed and examined all eight patients. The order of the presentation of the cases was balanced. No significant differences emerged in number of questions on history and physical examination or in the diagnoses and investigations considered by residents. Residents elicited significantly more historical data from the simulated patient; however, this was found to be due to a single case in which the real patient suffered from a neurological condition characterized by loss of memory. Residents correctly identified 67 percent of the patients as real or simulated against a chance figure of 50 percent. The implications of the study for training of simulated patients are discussed.

Clinical Competence↗
PubMed1982

The clinical reasoning of randomly selected physicians in general medical practice.

Most formal studies of the clinical reasoning process have been carried out on physicians in the sub-specialties and do not permit generalizations about the nature of the process in the average practising physician. Eighteen family physicians and 19 general internists were randomly selected and assigned to 1 of 4 standardized simulated patient problems in a natural practice setting. Sixty-two physician-patient encounters were studied by direct observation, videotape recall, and subsequent analysis of encounter transcripts by the physician. Physicians consistently developed multiple diagnostic hypotheses early in the patient encounter to guide their inquiry in a manner that would allow them to choose the appropriate hypothesis. Their approach was primarily problem-oriented and was not based on a routine inquiry intended to gather a comprehensive body of data as a basis for making subsequent diagnostic decisions. Little variation occurred between different patient problems. The accuracy and promptness of hypothesis generation were seen to play a significant role in the accuracy of diagnostic formulations. The process must be understood by those concerned with teaching and evaluating clinical competence.

Adult↗
PubMed1981

A comparison of behaviour on simulated patients and patient management problems.

This paper describes a study in which students were faced with a series of problems presented as patient management problems and as simulated patients (individuals trained to accurately portray a clinical problem). The subjects were sixty-five final-year medical students in a clinical clerkship in family medicine. Four clinical problems were used--each was developed in the PMP and simulated patient format. Each student completed one PMP and one simulated patient encounter (SPE) during the 2nd week of the 8-week clerkship, and a second PMP and SPE in the 7th week of the clerkship. Performance on the two formats was compared by determining the number of options, and the number of critical options (weighted +1 or +2 by a criterion panel) elicited in each section of the problem--history, physical examination, investigations and management. Students were found to elicit significantly more options in the PMP in all sections of the problem, an increase of from 20 to 150%. This difference due to format was of similar magnitude to the difference between problems and the proportion of observed variance in response due to the differences between formats and cases was consistently greater than the variance due to systematic differences between students. The findings of this study are consistent with previous studies comparing performance on PMPs to oral examinations and medical records, and raise some concern about the use of PMPs as a measure of competence in certification and licensure decisions.

Clinical Competence↗
PubMed1981

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.

Cross-Sectional Studies↗