Estudio de concordancia clínica en educandos de pre y postítulo en pediatría

Abstract

Evaluation of clinical skills in pre and postgraduate medical students should establish the level of concordance in each group according to defined objectives. Hypothesis: clinical skills in pregraduate students shows poor interobserver concordance levels (kappa index < 0.41) and improves in postgraduate students. Patients and methods: a pilot study of 50 cases permitted sample size estimates of 104 to 156 patients given a standard error of the kappa index of 0.08, and alfa error of 0.05 and the power to detect a difference of 0.20. Observers were random couples of interns (n = 11) and fist year residents (n = 10). The clinical findings evaluated were severity of illness, respiratory retractions, rales, respiratory distress and impairment of consciousness. Each record also included age, gender, nutritional status, diagnosis on admission, evaluation couple and date. Statistical analysis of the data included comparisons of proportions (Ji square) and of kappa indexes. Results: 358 children were admitted to the study, 206 were evaluated by residents and 152 by interns, both groups being of similar age, gender and nutritional status. Kappa indexes generated by intern couples were from –0.03 up to 0.17 and by residents 0.13 to 0.68. These figures were significantly better for residents only when evaluating impairment of consciousness and severity of illness. Reduction of evaluation categories to 2 levels showed significant improvement of kappa indexes only in the group of residents. The latter had better results than interns for all indexes except for respiratory distress. Conclusions: It is imperative to make a critical review of educational objectives and methods directed to the acquisition of clinical skills in pre and postgraduate medical students. The findings in this study show poor level of concordance in both groups and are hardly acceptable because interns have just had semiological training and residents in addition controlled practice.