Examination In Internal Medicine Research Articles

Development and Validation of a Cardiac Findings Checklist for Use With Simulator-Based Assessments of Cardiac Physical Examination Competence

Objective outcome measures for use with simulator-based assessments of cardiac physical examination competence are lacking. The current study describes the development and validation of an approach to scoring performance using a cardiac findings checklist. A cardiac findings checklist was developed and implemented for use with a simulator-based assessment of cardiac physical examination competence at a Canadian national specialty examination in internal medicine. Candidate performance as measured using the checklist was compared with global ratings of clinical performance on the cardiac patient simulator and with overall examination performance. Interrater reliability for scoring the checklist ranged from 0.95 for scoring correct findings to 0.72 for scoring incorrect findings. A summary checklist score had a Pearson correlation of 0.60 with overall candidate performance on the simulator-based station. Use of a cardiac findings checklist provides one objective measure of cardiac physical examination competence that may be used with simulator-based assessments.

Association Between Maintenance of Certification Examination Scores and Quality of Care for Medicare Beneficiaries

The relationship between physicians' cognitive skill and the delivery of evidence-based processes of care is not well characterized.Therefore, we set out to determine associations between general internists' performance on the American Board of Internal Medicine maintenance of certification examination and the receipt of important processes of care by Medicare patients. Physicians were grouped into quartiles based on their performance on the American Board of Internal Medicine examination. Hierarchical generalized linear models examined associations between examination scores and the receipt of processes of care by Medicare patients. The main outcome measures were the associations between diabetes care, using a composite measure of hemoglobin A(1c), and lipid testing and retinal screening, mammography, and lipid testing in patients with cardiovascular disease and the physician's performance on the American Board of Internal Medicine examination, adjusted for the number of Medicare patients with diabetes and cardiovascular disease in a physician's practice panel; frequency of visits; patient comorbidity, age, and ethnicity; and physician training history and type of practice. Physicians scoring in the top quartile were more likely to perform processes of care for diabetes (composite measure odds ratio [OR], 1.17; 95% confidence interval [CI], 1.07-1.27) and mammography screening (OR, 1.14; 95% CI, 1.08-1.21) than physicians in the lowest physician quartile, even after adjustment for multiple factors. There was no significant difference among the groups in lipid testing of patients with cardiovascular disease (OR, 1.00; 95% CI, 0.91-1.10). Our findings suggest that physician cognitive skills, as measured by a maintenance of certification examination, are associated with higher rates of processes of care for Medicare patients.

Foya Hospital, Liberia; Medicine in a Post Conflict Setting

I worked with Médecins Sans Frontières in the second half of 2006 as a medical doctor in a remote hospital in the West African nation of Liberia. I had just completed my physician specialist examinations in internal medicine but was required to draw on basic skills in many other areas including paediatrics, obstetrics and surgery. In the months prior I worked in remote Aboriginal communities in northern Australia, an experience which sadly, prepared me well for work in a third world setting.

54. Assessing cardiac physical examination competence using simulation technology and real patientss

Assessment of residents’ physical examination skills often involves the use of standardized patients lacking physical abnormalities. Simulation technology offers the potential benefit of mimicking physical abnormalities. The current study was undertaken to examine the relationship between physicians’ competence in cardiac physical examination as assessed using simulation technology compared to real patients. 
 An OSCE was created using 3 modalities of cardiac patients: real patients (RP) with cardiac abnormalities, standardized patients (SP) combined with a computer-based audio-video simulation of auscultatory abnormalities and a cardiopulmonary patient simulator (CPS). The same four cardiac diagnoses were tested with each modality.
 Participants were 28 internists, within 3 years of passing the Royal College of Physicians and Surgeons of Canada’s (RCPSC) Comprehensive Examination in Internal Medicine. At each station, two RCPSC examiners independently rated a participant’s physical examination technique and provided a global rating of clinical competence. The accuracy of a participant’s cardiac diagnosis for each patient was scored separately by two investigators.
 The inter-rater reliability between examiners, for the global rating outcome, was 0.76 for RP stations, 0.78 for SP stations and 0.75 for CPS stations. The correlations between participants’ global ratings on each modality were: RP vs. SP, r=0.19; RP vs. CPS, r=0.22; SP vs. CPS, r=0.57 (p < 0.01).
 A number of methodological limitations were highlighted during the study, including difficulties in truly matching patients within and between modalities, differential weighting of components into the examiners’ global ratings based on modality and limitations of case specificity. No modality provided a clear “gold standard” to assess residents’ cardiac physical examination competence. In the context of assessment, until these limitations are addressed, simulation modalities may not be directly interchangeable with real patients.
 Boulet JR, Swanson DB. Psychometric challenges of using simulations for high-stakes assessment. In: Dunn WF (ed). Simulators in critical care education and beyond. Des Plaines, IL: Society of Critical Care Medicine 2004; 119-30.
 Hatala R, Kassen BO, Nishikawa J, Cole G, Issenberg SB. Incorporating simulation technology in a Canadian national specialty examination: a descriptive report. Academic Medicine. 2005; 80(6):554-6. 
 Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005; 27(1):10-28.

Surgical training in Sweden

Introduction Sweden has six medical schools, from which 1,000 students graduate yearly. The programme in these schools is broadly identical and after 5.5 years at university the students do not receive a specific academic title, just a 'doctor's examination' (in Swedish). A graduate cannot, however, work as a physician after those 5.5 years. A further 18–24 months of internship are obligatory; all then work as doctors within surgery, internal medicine, psychiatry and finally as general practitioners. In total 7–7.5 years of study (with the last two years as an intern) are required, which include a final theoretical examination in surgery, internal medicine and psychiatry. Having passed those examinations the doctor receives certification from the Swedish National Board of Health and may work as a 'board-certified doctor'.

Assessing Cardiac Physical Examination Skills Using Simulation Technology and Real Patients: A Comparison Study.

BACKGROUND: Simulation technology provides additional methods to assess physicians’ clinical competence in physical examination. The current study examines the relationship between internists’ competence in cardiac physical examination as assessed using simulation technology compared to real patients. METHODS: We assessed internists’ competence in cardiac physical examination skills and bedside diagnostic accuracy during a 12 station OSCE. The OSCE contained 3 modalities of cardiac patients: 4 stations using real patients (RP) with cardiac abnormalities, 4 stations using standardized patients (SP) combined with a computer-based audio-video simulation of auscultatory abnormalities and 4 stations using a cardiopulmonary patient simulator (CPS). Four cardiac diagnoses were tested: normal, mitral regurgitation, aortic stenosis and mitral stenosis. Cardiac diagnoses and the specific cardiac findings for each diagnosis were matched across modalities. Participants were 28 internists, within 3 years of passing the Royal College of Physicians and Surgeons of Canada’s (RCPSC) Comprehensive Examination in Internal Medicine. At each station, two RCPSC examiners independently rated a participant’s physical examination technique and provided a global rating of clinical competence. The accuracy of a participant’s cardiac diagnosis for each patient was scored separately by two investigators. RESULTS: The inter-rater reliability between examiners, for the global rating outcome, was 0.76 for RP stations, 0.78 for SP stations and 0.75 for CPS stations. Although there was no significant difference between participants’ mean global ratings for each modality (effect size = 0.05, p 0.05), the correlations between participants’ performance on each modality were modest (Table 1).Table 1: Correlations between OSCE station modalities, for 3 outcome measuresCONCLUSIONS: While patient findings and diagnoses were matched as close as possible, variability among the real patients and logistical limitations with the simulation stations could affect the correlations between modalities. The results suggest that simulation technology used purely for assessment purposes may not be interchangeable with real patients. Future work will include increasing the number of cardiac conditions and improving the objective measurement of performance.

A technique for identifying three diagnostic findings using association analysis

In diagnosing diseases in clinical practice, a combination of three clinical findings is often used to represent each disease. This is largely because it is often difficult or impractical to assess for all possible combinations of symptoms and abnormal exam findings that occur in any particular disease. For most diseases, diagnostic triads are based on empirical observations. In this study, we determined diagnostic triads for chronic diseases using data mining procedures. We also verified the combinations' validity as well as our procedure for determining them. We used symptoms and examination findings from 477 patients with chronic diseases, collected as part of a 35-year longitudinal study begun in 1968. For each patient there were 295 items from examinations in internal medicine, dermatology, ophthalmology, dentistry and blood tests. We judged each item to be either normal or abnormal, and restricted the analysis to the abnormal findings. To analyze such an exhaustive assortment, we used the data mining technique of association analysis. The analysis generated three clinical findings for each disease. Diseases were defined based on blood tests. Searching through all 295 items to find the three most useful clinical findings would be impractical on a commodity PC. However, by excluding normal items, we were able to sufficiently reduce the total number of combinations so as to make combinatorial analysis on a PC feasible. In addition to more accurate diagnoses, we believe our technique can identify those diagnostic data that are more cost effective in terms of time and other resources required for their collection.

The Use of the Objective Structured Clinical Examination (OSCE) in Small-Animal Internal Medicine and Surgery

The Objective Structured Clinical Examination (OSCE) has been used extensively to evaluate clinical skill of medical students. This article reports on its adaptation to veterinary medicine.

Assessing the mini-Clinical Evaluation Exercise in comparison to a national specialty examination

To evaluate the reliability and validity of the Mini-Clinical Evaluation Exercise (mini-CEX) for postgraduate year 4 (PGY-4) internal medicine trainees compared to a high-stakes assessment of clinical competence, the Royal College of Physicians and Surgeons of Canada Comprehensive Examination in Internal Medicine (RCPSC IM examination). Twenty-two PGY-4 residents at the University of British Columbia and the University of Calgary were evaluated, during the 6 months preceding their 2004 RCPSC IM examination, with a mean of 5.5 mini-CEX encounters (range 3-6). Experienced Royal College examiners from each site travelled to the alternate university to assess the encounters. The mini-CEX encounters assessed a broad range of internal medicine patient problems. The inter-encounter reliability for the residents' mean mini-CEX overall clinical competence score was 0.74. The attenuated correlation between residents' mini-CEX overall clinical competence score and their 2004 RCPSC IM oral examination score was 0.59 (P = 0.01). By examining multiple sources of validity evidence, this study suggests that the mini-CEX provides a reliable and valid assessment of clinical competence for PGY-4 trainees in internal medicine.

UroSurf – ein interaktives Lernprogramm zur Urindiagnostik

The examination of the urine is of great significance in medical diagnostics. This can be seen in the high number of ordered urin analyses. Accordingly, the interpretation of urinalysis is part of the Swiss Catalogue of Learning Objectives of Undergraduate Medical Training as well as the licencing examinations in Internal Medicine. Due to its simple handling, its low costs and the many parameters measured, the chemical urinalysis with a stix is an ideal screening test. In contrast to stix tests, the interpretation of urine sediments is far from being trivial. The examiners must be accordingly trained in order to recognize the typical abnormalities of the urine sediment. Learning how to interpret microscopic findings is tedious and time-consuming if technical aids such as a microscope-mounted video camera are lacking. An additional handicap is that urine sediments can not be kept for a long time as it is the case with blood smears. Therefore an interactive learning program such as UroSurf offers many possibilities to lessen these problems. UroSurf is a web-based learning program consisting of three modules. In the module "Urindiagnostik", urine diagnostics are presented in a textbook like style. In the module "Klinische Fallbeispiele" (clinical case samples), urine diagnostics are put into a clinical context. In the module "Urinsediment-Bilder" (images), learners can train and assess their skills in interpreting urine sediments.

Correlation of CPX Scores with the Scores of the Clinical Clerkship Assessments and Written Examinations

Purpose: Recently, the clinical performance examination(CPX) using standardized patients has been introduced to several Korean medical schools. The purpose of this paper is to evaluate the correlation of CPX scores with the scores of other clinical clerkship assessments and written examinations. Methods: We evaluated the correlation of the scores of CPX, which was administered to third-year medical students(n=230) at Seoul National University College of Medicine in January 2005, with the scores of a slide examination in internal medicine, an objective structured clinical examination(OSCE) in pediatrics and obstetrics/gynecology, and the written examinations in internal medicine and general surgery. Results: CPX scores showed a mild correlation with the scores of the slide examination in internal medicine and OSCE in pediatrics and obstetrics/gynecology(r=0.19, 0.28, 0.30). CPX scores were also mildly correlated with written examination scores in internal medicine but not associated with those in general surgery. Conclusion: Considering the mild correlation of CPX scores with scores of other clinical clerkship assessments and written examinations, CPX should be affirmatively considered as an examination complementary to previous examinations.

Experience of Objective Structured Clinical Examination in Gyeong-Sang National University College of Medicine

Purpose: The third year students at Gyeong-Sang National University College of Medicine were asked to perform objective structured clinical examination(OSCE) at the end of the 2004 academic year. In this article, we analysed the correlation among the scores of OSCE with those of Final Term Examination in Internal Medicine(FTE), Clerkship Performance in Internal Medicine(CP) and Case Conference Examination(CCE), which assess knowledge, skill and attitude, and problem solving ability in medicine, respectively. We also analyzed difficulty and discrimination indexes of the test questions or evaluation criteria, and assessed their objectivity. Methods: 1) Relevance: the pearson correlation analysis was performed on the scores of 85 students from 6 OSCE stations, FTE, CP and CCE. 2) Analysis on the evaluation criteria: the difficulty and discrimination indexes of the 59 evaluation criteria were calculated. 3) Objectivity: in order to assess objectivity in the scores, the Student t-test was performed on the scores of students from 4 OSCE stations where there was a change in the examiners after the morning sessions and on the students from 2 OSCE stations that had no change of examiners. Results: 1) Relevance: Correlation coefficients between the scores of OSCE and FTE, CP or CCE were 0.335, 0.326 and 0.421, respectively(p＜0.01). 2) Analysis on the evaluation criteria: difficulty indexes of the 59 criteria ranged from 0.15 to 0.98, and 43% of the criteria belonged to the acceptable range. Discrimination indexes ranged from -0.22 to 0.61, and 69% of the criteria were acceptable. 3) Objectivity: The student t-test showed significant differences between the scores of the morning and afternoon sessions in 2 of the 4 stations, where the examiners were changed in the afternoon(p＜0.01). Conclusion: Our results suggest that OSCE performed in 2004 may have relevance to a valid tool in assessing clinical competence of medical students in terms of knowledge, skill, attitude and problem solving ability. However, in order to reuse the test materials in the future, evaluation criteria need to be refined further based on difficulty and discrimination indexes, and measures to improve objectivity of examiners should also be studied.

A training course for the Israeli phase I written board examination in internal medicine increases the success rate of foreign graduate physicians

Background Foreign graduate residents in internal medicine perform poorly on the Israeli phase I written board examination as compared to local graduates from Israeli medical schools. The aim of this study was to determine the effect of a preparatory course, aimed at foreign graduates, on their success rate in the Israeli phase I written board examination in internal medicine. Methods The preparatory course consisted of seven 4-h weekly meetings that took place 3 months before the board examination. Participants were divided into two classes, each containing approximately 35 residents. Each meeting was dedicated to two fields of internal medicine and consisted of a multiple-choice examination, followed by a guided discussion with a senior physician. A pre-test was given at the end of the course and its results were compared to those of the official examination. Residents who took the official examination but who did not participate in the course served as controls. Results The combined 2-year (1999–2000) success rate on the official phase I board examination of foreign graduates who took the course was significantly higher than that of controls: 41.7% vs. 30.4%, respectively ( p < 0.019). The results of the course pre-test were highly predictive of the success on the board examination ( r = 0.481, p < 0.01). The course did not significantly improve the success rate of the Israeli graduates. Conclusion A short, focused, preparatory course significantly increases the success rate of foreign graduate residents on the Israeli phase I written board examination in internal medicine. Performance in the course is highly predictive of the success rate on the official board examination.

Incorporating Simulation Technology in a Canadian Internal Medicine Specialty Examination: A Descriptive Report

High-stakes assessment of clinical performance through the use of standardized patients (SPs) is limited by the SP's lack of real physical abnormalities. The authors report on the development and implementation of physical examination stations that combine simulation technology in the form of digitized cardiac auscultation videos with an SP assessment for the 2003 Royal College of Physicians and Surgeons of Canada's Comprehensive Objective Examination in Internal Medicine. The authors assessed candidates on both the traditional stations and the stations that combined the traditional SP examination with the digitized cardiac auscultation video. For the combined stations, candidates first completed a physical examination of the SP, watched and listened to a computer simulation, and then described their auscultatory findings. The candidates' mean scores for both types of stations were similar, as were the mean discrimination indices for both types of stations, suggesting that the combined stations were of a testing standard similar to the traditional stations. Combining an SP with simulation technology may be one approach to the assessment of clinical competence in high-stakes testing situations.

Conference attendance and performance on the in-training examination in internal medicine

The objective of this study was to describe the relationship between attendance at conferences during residency training and residents’ performance on the In-Training Examination (ITE) in Internal Medicine. Nineteen house officers participated in the study. Conference attendance records were retrospectively reviewed for the one-year period preceding the ITE (pre-ITE), and in the three-month period after house officers received their ITE scores (post-ITE). After receiving their scores, participants completed a questionnaire asking about study habits and opinions about conferences. Attendance was taken at 126/165 (76.4%) conferences pre-ITE and 32/42 (76.2%) conferences post-ITE. House officers attended a mean of 35% (range, 10–59) of the conferences pre-ITE and 32% (range, 9–75) post-ITE (p = 0.365). There was no correlation between prior conference attendance and ITE scores (Spearman correlation coefficient −0.230, p = 0.34), and no correlation between score and conference attendance post-ITE (Spearman correlation coefficient 0.174, p = 0.48). Participation in clinical rotations also failed to influence ITE scores in that content area (all p > 0.05). The findings of this study suggest conference attendance does not influence ITE scores. Medical educators may need to rethink and study how best to impart medical knowledge.

Cardiology's workforce shortage: implications for patient care and research.

The common wisdom at the end of the 20th century was that the United States was training too many specialists, including cardiologists.1 By 2001, however, there was increasing evidence that the supply of cardiologists was not meeting the growing demand. That year, as president-elect of the American College of Cardiology (ACC), I appointed a task force to evaluate cardiology workforce. The task force undertook a 2-year process of literature review, hypothesis generation, research design, data acquisition, and analysis. This intense effort included a Bethesda Conference at which consensus was achieved on a report that will be published in the Journal of the American College of Cardiology . Based on various types of information and data, the ACC task force concluded that the United States is facing a shortage of cardiologists. This will reduce access to specialty care of proven benefit and will undermine our nation’s vital cardiovascular research effort. The Bethesda Conference report includes 8 working group documents that recommend several short- and intermediate-term strategies to help narrow the growing demand-supply gap for cardiologists (see Table 1). Some recommendations can be implemented at a local practice or institution level. Others will require a series of complex and coordinated actions at a national level. Hopefully, the report will catalyze actions by academic medical centers, regulatory organizations, federal policymakers, professional societies, and others that influence the output of cardiovascular specialists. View this table: TABLE 1. Working Groups of the ACC Task Force on Workforce Several things continue to drive demand for cardiologists. Elsewhere, I have argued that various scientific, social, and demographic “demand catalysts” outweigh factors that might decrease demand for cardiologists during the next decade2 (see Table 2). Although the relative influence of each demand factor will change over time, one thing is certain: the cardiovascular disease burden in the United States …

Telfer B. Reynolds, M.D. (1921-2004)†

Telfer B. Reynolds, M.D. (1921-2004)†

The In-Training Examination in Internal Medicine

The In-Training Examination in Internal Medicine

The importance of rectoscopy and colonoscopy in Internal Medicine

The endoscopic examination of the large intestine can be considered today a routine examination in internal medicine. Since the introduction of flexible videoendoscopy, evaluating diseases in the distal colon using rectoscopy has become less important. Anoproctoscopy is an obligatory component for a complete colon diagnostic after a flexible ileo-colonoscopy has been performed. Colonoscopy has improved significantly the diagnosis and therapy of diseases in the large intestine since it has been introduced more than 30 years ago. By introducing modern videocolonoscopy in addition to other instruments, there is today a broad spectrum of diagnostic and therapeutic indications available. Specifically, due to its frequency and prognostic relevance, colonoscopy has become the most powerful and important procedure in the early detection and prevention of colon cancer.

Use of an objective, structured clinical examination as a component of the final-year examination in small animal internal medicine and surgery.

Use of an objective, structured clinical examination as a component of the final-year examination in small animal internal medicine and surgery.