Article

The use of standardized patients to evaluate family medicine resident decision making.

Wilson Family Practice Residency, Johnson City, NY 13790, USA.
Family medicine (Impact Factor: 0.85). 04/2007; 39(4):261-5.
Source: PubMed

ABSTRACT This study was intended to assess the usefulness of standardized patients (SPs) in the evaluation of family medicine residents' clinical decision-making skills in ambulatory settings.
A pool of SPs was trained about the symptoms of one of three clinical conditions (depression, headache, or irritable bowel syndrome). These patients were then surreptitiously incorporated into the office hours of 11 residents on one occasion during their second year and once during their third year of training. A different SP was used at each encounter, but the same clinical case was presented each year for that particular resident. The SPs were given a questionnaire after each office visit to evaluate whether the resident completed elements of history, physical exam, clinical decision making specific to their case, and to report their satisfaction with the encounter. In addition, the assessment component of the resident's progress notes for each SP visit was reviewed by a single examiner to determine if the correct diagnosis was made by the resident.
The residents showed a statistically significant decrease in the percentage of checklist items completed for all clinical cases from the second year (82.70%) to the third year (75.55%). However, the average patient satisfaction was unchanged, as was the number of correct diagnoses, even though fewer questions were asked.
The use of SPs is a feasible and potentially useful method for evaluating family medicine resident decision making. Several factors may account for the differences in resident performance with SP scenarios.

0 Bookmarks
 · 
83 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The current maxim concerning diagnosis and treatment of mood and anxiety disorders is that family physicians fail to appropriately respond to patients with anxiety and depression. This estimate is based upon a collection of studies that have found that accurate recognition in general practice occurred in 9% to 75% of patients with depression, and 34% to 50% of patients with anxiety. However, most studies have found that more than half of physicians accurately detected depression and anxiety in their patients. This dissertation examined physicians’ responses (detection, treatment, and follow-up) to clinical scenarios of patients presenting with symptoms of either depression or anxiety. Furthermore, this study evaluated the associations between physicians’ responses and physician attributes (personal and professional), organizational setting, information/resource use, and barriers to care. A cross-sectional study of Saskatchewan family physicians yielded a response rate of 49.7% (N=331/666). The results of this study revealed that most physicians provided appropriate depression and anxiety care with respect to recognition of disorders and follow-up care. Specifically, 85.4% of physicians provided an accurate tentative diagnosis of depression, and 86.3% provided an accurate tentative diagnosis of anxiety; 82.5% of physicians suggested adequate follow-up depression care while 79.4% offered adequate follow-up anxiety care. However, a notable proportion of physicians did not provide effective treatment; 65.6% of physicians recommended effective (immediate) anxiety treatment, and 55.6% recommended effective (immediate) depression treatment. ii This study found that physicians’ provision of care to patients with anxiety and depression was more likely to be associated with their personal attributes, organizational setting, and information/resource use than with their professional attributes. First, neither tentative diagnosis of depression nor tentative diagnosis of anxiety was significiantly associated with any of the tested measures. Second, ineffective treatment of depression was significantly more likely among physicians who were female, educated at the undergraduate level in Canada (versus elsewhere), scored lower on anxiety attitude factor 1 (social context view of anxiety amenable to intervention), had a low patient load (< 100 patients/week), and used medical textbooks to make specific clinical decisions; ineffective treatment of anxiety was significantly more likely among physicians who had completed their undergraduate and postgraduate medical training in Canada (versus elsewhere), had a low patient load ( <100 patients/week), did not practice in a private office/clinic, and used colleagues within as well as outside their main patient care setting to update their general medical knowledge. Third, physicians were significantly more likely to provide inadequate follow-up care to the depressed patient if they were in solo practice and used drug manuals to update their general medical knowledge, and significantly more likely to provide inadequate follow-up care to the anxious patient if they (the physician) were female and did not use mental health professionals to update their general medical knowledge. Results indicated that after controlling for the effects of other factors, physicians with low patient loads were three times more likely to provide ineffective treatment of depression than physicians with high patient loads. Furthermore, when holding the effects of all other factors constant, physicians who had completed postgraduate training in Canada were approximately five times more likely to provide ineffective treatment of the anxious patient than physicians who had completed their postgraduate training outside of Canada.
    Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, 09/2009, Degree: Doctor of Philosophy, Supervisor: Carl D'Arcy
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To report the performance of various contact lenses and lens care solution combinations based on the combined response of subjective comfort and adverse events (AEs). A retrospective analysis of 28 lens/solution combinations each tested on approximately 40 participants who wore their assigned combination on a daily wear basis and were followed for a 3-month period, with visits at baseline, 2 weeks, and 1 and 3 months. Lenses included frequent replacement and daily disposables. Solutions included hydrogen peroxide and multipurpose types. Subjective comfort (scale of 1 to 10) and AEs were collected and reported as a group mean and percentage, respectively. The data were converted into a ratio between 0 and 1 to represent the relative performance within the combination series, with a higher ratio indicating better performance in both AE rates and comfort. The overall AE rate was 3.6 events per 100 participant-months (95% confidence interval [95% CI], 2.7 to 4.7%). The rate was found to be lower in daily disposables compared with that in daily wear lenses (3.1 vs. 10.9%, p < 0.001). The overall comfort on insertion rating was 8.3 (95% CI, 8.1 to 8.4), and comfort at end of day was 7.2 (95% CI, 7.0 to 7.4). Based on the 28 lens/solution combinations, there was no significant correlation between overall AE rates and comfort on insertion or at end of day (Pearson correlation, -0.34, p = 0.08; and Pearson correlation, -0.23, p = 0.25, respectively). Less than 18% of the combinations tested combined good comfort with low AE rates. Both subjective comfort responses and AE rates varied according to the combination of lens type and care system in use. The combinations with the best comfort ratings did not necessarily have a favorable AE rate. Practitioners can maximize behavior with respect to both these factors by choosing an appropriate care system for the lenses they prescribe.
    Optometry and vision science: official publication of the American Academy of Optometry 07/2013; 90(7):674-81. DOI:10.1097/OPX.0000000000000008 · 1.53 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Residents must learn which infants require a lumbar puncture (LP), a clinical decision-making skill (CDMS) difficult to evaluate because of considerable practice variation. The authors created an assessment model of the CDMS to determine when an LP is indicated, taking practice variation into account. The objective was to detect whether script concordance testing (SCT) could measure CDMS competency among residents for performing infant LPs. In 2011, using a modified Delphi technique, an expert panel of 14 attending physicians constructed 15 case vignettes (each with 2 to 4 SCT questions) that represented various infant LP scenarios. The authors distributed the vignettes to residents at 10 academic pediatric centers within the International Simulation in Pediatric Innovation, Research, and Education Network. They compared SCT scores among residents of different postgraduate years (PGYs), specialties, training in adult medicine, LP experience, and practice within an endemic Lyme disease area. Of 730 eligible residents, 102 completed 47 SCT questions. They could earn a maximum score of 47. Median SCT scores were significantly higher in PGY-3s compared with PGY-1s (difference: 3.0; 95% confidence interval [CI] 1.0-4.9; effect size d = 0.87). Scores also increased with increasing LP experience (difference: 3.3; 95% CI 1.1-5.5) and with adult medicine training (difference: 2.9; 95% CI 0.6-5.0). Residents in Lyme-endemic areas tended to perform more LPs than those in nonendemic areas. SCT questions may be useful as an assessment tool to determine CDMS competency among residents for performing infant LPs.
    Academic medicine: journal of the Association of American Medical Colleges 11/2013; DOI:10.1097/ACM.0000000000000059 · 2.34 Impact Factor

Full-text (2 Sources)

Download
66 Downloads
Available from
Jun 5, 2014