Levels Of Medical Training Research Articles

Development and validation of a geriatric knowledge test for medical students.

To assesses the reliability and validity of a geriatrics knowledge test designed for medical students. Cross-sectional studies. An academic medical center. A total of 343 (86% of those sampled) medical students participated in the initial study, including 137 (76%) first-year, 163 (96%) third-year, and 43 (86% of those sampled) fourth-year students in the 2000-2001 academic year. To cross-validate the instrument, another 165 (92%) third-year and 137 (76%) first-year students participated in the study in the 2001-2002 academic year. An 18-item geriatrics knowledge test was developed. The items were selected from a pool of 23 items. An established instrument assessing the clinical skills of medical students was included in the validation procedure. The instrument demonstrated good reliability (Cronbach alpha=0.80) and known-groups and concurrent validity. Geriatrics knowledge scores increased progressively with the higher level of medical training (mean percentage correct=31.3, 65.3, and 66.5 for the first-year, third-year, and fourth-year classes, respectively, P<.001). A significant (P<.01) relationship was found between the third-year students' geriatrics knowledge and their clinical skills. Similar results, except the relationship between knowledge and clinical skills, were found in the cross-validation study, supporting the reliability and known-groups validity of the test. The 18-item geriatrics knowledge test demonstrated sound reliability and validity. The average scores of the student groups indicated substantial room for growth. The relationship between geriatrics knowledge and overall clinical skills needs further investigation.

Adam hammer (1818 - 1878) - remarks on a forgotten pioneer of ether anaesthesia in obstetrics

Adam Hammer, born in 1818, and working as a doctor for the poor since 1847 in Mannheim, was the first person in the German speaking world to use ether for pain relief during labor on February 18th 1847. He took part in the abortive April 1848 Revolution in Mannheim - a pinnacle of German liberalism and later of political radicalism, which attented to abolish the Monarchy and introduce a democratic Republic. After the revolution was put down, Hammer emigrated to the United States and settled down in St. Louis, Missouri. Remaining politically active, he joined the Republican Party, founded in 1854 and served as a military surgeon in the Union Army during the American Civil War. Even before the war, he was engaged in efforts to improve the level of medical training in America and was involved with the foundation of High Schools which offered training courses along the lines of German universities. His ideas and innovations were not introduced immediately, but had a significant impact on medical training methology later on in the US. During a visit in Europe in 1876, he was the first to diagnose a coronary thombosis as the cause of a heart attack on a live patient. The diagnosis was later confirmed by post-morten autopsy on the patient. In 1877 he returned to Germany and died one year later. The biography of Adam Hammer mirrows that of many other German-Americans whose emigration proved to be a gain for America but a loss for Germany. This story was destinated to be repeated in terrible circumstances some decades later.

Do patients understand their physician's level of training? a survey of emergency department patients.

To assess patients' understanding of levels of training and responsibilities for residents, medical students, and attendings in the emergency department as well as their degree of comfort in being cared for by a physician-in-training. In 1999, a questionnaire was administered to a convenience sample of 430 adult patients and family members in a university emergency department. The questionnaire asked for demographic information and contained 17 questions addressing the different levels of medical training and seven opinion-based questions on patients' willingness to have physicians-in-training care for them. Respondents answered 65% of the knowledge-based questions about physicians' training correctly. Only 43% understood that residents are always supervised when caring for patients, and 30% thought attendings required supervision by a resident. Respondents with education greater than a high school diploma answered more questions correctly (71% versus 59%; p <.05). A total of 80% felt it was very important to know their physician's level of training, but only 58% reported actually knowing the level of training. Only 62% felt comfortable knowing that their physician might be a supervised physician-in-training. In addition, despite the fact that this survey took place at a teaching hospital, 22% of respondents prefer not to be treated in a teaching hospital. Patients and their families do not fully understand the roles and responsibilities of the physicians-in-training that may be caring for them despite feeling it is important to know their physicians' level of training.

Clinical reasoning: the relative contribution of identification, interpretation and hypothesis errors to misdiagnosis

The aim of this study was to identify and describe the types of errors in clinical reasoning that contribute to poor diagnostic performance at different levels of medical training and experience. Three cohorts of subjects, second- and fourth- (final) year medical students and a group of general practitioners, completed a set of clinical reasoning problems. The responses of those whose scores fell below the 25th centile were analysed to establish the stage of the clinical reasoning process—identification of relevant information, interpretation or hypothesis generation—at which most errors occurred and whether this was dependent on problem difficulty and level of medical experience. Results indicate that hypothesis errors decrease as expertise increases but that identification and interpretation errors increase. This may be due to inappropriate use of pattern recognition or to failure of the knowledge base. Furthermore, although hypothesis errors increased in line with problem difficulty, identification and interpretation errors decreased. A possible explanation is that as problem difficulty increases, subjects at all levels of expertise are less able to differentiate between relevant and irrelevant clinical features and so give equal consideration to all information contained within a case. It is concluded that the development of clinical reasoning in medical students throughout the course of their pre-clinical and clinical education may be enhanced by both an analysis of the clinical reasoning process and a specific focus on each of the stages at which errors commonly occur.

The Accuracy of Predicting Cardiac Arrest by Emergency Medical Services Dispatchers: The Calling Party Effect

Abstract Objectives: To analyze the accuracy of paramedic emergency medical services (EMS) dispatchers in predicting cardiac arrest and to assess the effect of the caller party on dispatcher accuracy in an advanced life support, public utility model EMS system, with greater than 90,000 calls and greater than 60,000 transports per year. Methods: This was a retrospective analysis from January 1, 2000, through June 30, 2000, of 911 calls with dispatcher‐assigned presumptive patient condition (PPC) or field diagnosis of cardiac arrest. Sensitivity and positive predictive value (PPV) of the PPC code for cardiac arrest by calling parties were calculated. Homogeneity of sensitivity and PPV of the PPC code for cardiac arrest by calling parties was studied with chi‐square analysis. Relevant proportions, relative risk ratios, and associated 95% confidence intervals (95% CIs) were calculated. Student's t‐test was used to compare quality assurance scores between calling parties. Results: There were 506 patients included in the study. Overall sensitivity for dispatcher‐assigned PPC of cardiac arrest was 68.3% (95% CI = 63.3% to 73.0%) with a PPV of 65.0% (95% CI = 60.0% to 69.7%). There was a significant difference in the PPV for the EMS dispatcher diagnosis of cardiac arrest depending on the type of caller (χ2= 17.34, p &lt; 0.001). Conclusions: A higher level of medical training may improve dispatch accuracy for predicting cardiac arrest. The type of calling party influenced the PPV of dispatcher‐assigned condition.

Computer-assisted instruction of carpal bone radiograph interpretation

This paper describes the development of a computer-assisted self-directed learning module to teach carpal bone radiograph interpretation to clinical clerks, and the evaluation of its efficacy as a teaching tool. The module was developed using commercially available authoring software and in collaboration with radiologists. Following an eight-month period where the module was a mandatory component of the clerkship rotation in emergency medicine, a convenience sample of 36 volunteers from various levels of medical training were recruited, and their ability to interpret carpal radiographs was tested in an objective structured clinical examination (OSCE). The scores of the clinical clerks who had completed the module were shown to be similar to the scores of emergency medicine residents with specific experience and training in this skill (mean: 5 vs. 6), and different from the scores of trainees who had not completed the module and had no specific training in this skill (mean: 5 vs. 2). This study suggests that our module may be an effective tool in teaching this skill to clinical clerks.

Assessing clinical reasoning: a method to monitor its development in a PBL curriculum

The aim of this study was to develop and trial a method to monitor the evolution of clinical reasoning in a PBL curriculum that is suitable for use in a large medical school. Termed Clinical Reasoning Problems (CRPs), it is based on the notion that clinical reasoning is dependent on the identification and correct interpretation of certain critical clinical features. Each problem consists of a clinical scenario comprising presentation, history and physical examination. Based on this information, subjects are asked to nominate the two most likely diagnoses and to list the clinical features that they considered in formulating their diagnoses, indicating whether these features supported or opposed the nominated diagnoses. Students at different levels of medical training completed a set of 10 CRPs as well as the Diagnostic Thinking Inventory, a self-reporting questionnaire designed to assess reasoning style. Responses were scored against those of a reference group of general practitioners. Results indicate that the CRPs are an easily administered, reliable and valid assessment of clinical reasoning, able to successfully monitor its development throughout medical training. Consequently, they can be employed to assess clinical reasoning skill in individual students and to evaluate the success of undergraduate medical schools in providing effective tuition in clinical reasoning.

Effects of Perceptions and Mentorship on Pursuing a Career in Academic Medicine in Obstetrics and Gynecology

To understand the perceptions of residents and Fellows in obstetrics and gynecology about the impacts of race or ethnicity, gender, and mentorship experiences on pursuing careers in academic medicine. Two surveys were administered: one to a sample of 2,000 Fellows of the American College of Obstetricians and Gynecologists, and one to the 4,814 obstetrics and gynecology residents taking the 1998 in-training examination. The questionnaires asked about demographics, perceptions about careers in academic medicine, and residents' experiences with mentorship. Response rates were 96.8% for residents and 40.6% for FELLOWS: Of the residents, 26.1% indicated they would not consider a career in academic medicine. First-year women residents were more inclined to pursue careers in academic medicine than were first-year men (p =.042), but their interest declined during residency. Women residents (43%)-especially minorities-felt that men were mentored and recruited more for faculty positions, while men (38%) felt that women were mentored and recruited more. Fellows' reports of recruitment did not differ by gender. Most white residents did not perceive racial or ethnic bias in mentoring or recruiting, while most non-white residents did. Almost one third of non-white women residents felt that supervisors were more likely to condescend to women and minority individuals. It is likely that neither men nor women residents in obstetrics and gynecology receive adequate mentorship for careers in academic medicine. Perceptions of bias are a serious barrier to developing racial, ethnic, and gender diversity in leadership positions.

EVIDENCE-BASED CLINICAL DECISION MAKING IN SPORTS INJURY MANAGEMENT

Traditionally, sports medicine practitioners have evaluated and treated injured athletes and other physically active individuals based on their own levels of medical training, clinical experience, and common sense. To this day, many widely accepted sports injury assessment techniques and rehabilitation protocols lack the scientific evidence to support their use. In the new paradigm of evidence-based clinical practice, sports medicine practitioners will evaluate and treat their patients utilizing a skillful combination of their medical background, clinical experience, and information gleaned from systematic, unblased, highly reproducible research studies. With an ever-increasing number of clinical sports medicine studies being published each year, there remains a need to analyze the information available in the literature in order to make evidence-based decisions on the efficacy of new and existing sports injury physical assessment techniques and sports injury rehabilitation protocols. The objectives of this symposium are: (1) to review the statistical methods and importance of determining validity, reliability, and measures of specificity and sensitivity relative to the clinical decision making process in sports medicine; (2) to analyze the existing literature and present pertinent examples of evidence-based clinical decision making relative to the use of sports injury physical assessment techniques; and (3) to analyze the existing literature and present selected examples of evidence-based clinical decision making relative to sports injury rehabilitation and treatment protocols. We will present a model for evaluating and grading the available levels of evidence, ranging from large randomized clinical trials with clear-cut results to single subject case studies.

Prognostication and certainty in the pediatric intensive care unit.

Prognostication is central to developing treatment plans and relaying information to patients, family members, and other health care providers. The degree of confidence or certainty that a health care provider has in his or her mortality risk assessment is also important, because a provider may deliver care differently depending on their assuredness in the assessment. We assessed the performance of nurse and physician mortality risk estimates with and without weighting the estimates with their respective degrees of certainty. Subjective mortality risk estimates from critical care attendings (n = 5), critical care fellows (n = 9), pediatric residents (n = 34), and nurses (n = 52) were prospectively collected on at least 94% of 642 eligible, consecutive admissions to a tertiary pediatric intensive care unit (PICU). A measure of certainty (continuous scale from 0 to 5) accompanied each mortality estimate. Estimates were evaluated with 2 x 2 outcome probabilities, the kappa statistic, the area under the receiver operating characteristics curve, and the Hosmer and Lemeshow goodness-of-fit chi(2) statistic. The estimates were then reevaluated after weighting predictions by their respective degree of certainty. Overall, there was a significant difference in the predictive accuracy between groups. The mean mortality predictions from the attendings (6.09%) more closely approximated the true mortality rate (36 deaths, 5.61%) whereas fellows (7.87%), residents (10.00%), and nurses (16.29%) overestimated the mean overall PICU mortality. Attendings were more certain of their predictions (4.27) than the fellows (4.01), nurses (3.79), and residents (3.75). All groups discriminated well (area under receiver operating characteristics curve range, 0.86-0.93). Only PICU attendings and fellows did not significantly differ from ideal calibration (chi(2)). When mortality predictions were weighted with their respective certainties, their performance improved. The level of medical training correlated with the provider's ability to predict mortality risk. The higher the level of certainty associated with the mortality prediction, the more accurate the prediction; however, high levels of certainty did not guarantee accurate predictions. Measures of certainty should be considered when assessing the performance of mortality risk estimates or other subjective outcome predictions.

The Clinical Detection of Scleral Icterus: Observations of Multiple Examiners

Sixty-two medical observers at various levels of medical training examined six patients for the presence or absence of scleral icterus in a double-blind survey. At a total serum bilirubin of 42.8 mmol/l (2.5 mg/dl) and 53.0 mmol/l (3.1 mg/dl), 58% (95% confidence interval [CI] 33-80%) and 68% (95% CI 46-85%) of examiners detected the presence of scleral icterus, respectively. Level of training appeared to influence specificity, as 6 of 8 apparent false-positives (total serum bilirubin = 12.0 mmol/l [0.7 mg/dl] and the presence of scleral icterus) were attributable to medical students. Level of training did not appear to influence sensitivity, as 3 of 11 apparent false-negatives (total serum bilirubin = 66.7 mmol/l [3.9 mg/dl] and the absence of detection of scleral icterus) were not attributable to medical students (p = 0.278). Even at the often-quoted estimate of 42.8 mmol/l (2.5 mg/dl) at which at scleral icterus is detected, approximately one-third of medical examiners in our study did not detect scleral icterus.

Teaching psychosomatic medicine: utilizing concurrent perspectives.

Teaching psychosomatic medicine is a challenge in the contemporary medical culture that rewards technology and empiricism. The biopsychosocial model of disease offers an overview about psychosomatic medicine for educating students at all levels of medical training. The teacher can then utilize the various perspectives found in psychiatry to emphasize that the medical model of disease states which concur with the meaningful elements of patient's life narratives, their personality style and possible motivated behaviors fully illuminates psychosomatic illness.

Physicians, preventive care, and applied nutrition: selected literature.

The authors review a core of 25 articles (dating from 1982 through 1991) regarding medical school curricula and physicians' knowledge, attitudes, and practices related to nutritional care, with a focus on prevention of coronary heart disease through cholesterol control. They supplement this review by discussing the relation of the core articles' results to those of additional articles, which focus more generally on physicians' health promotion and patient counseling. While there appear to be modest increases in attention to nutrition at various levels of medical training and some improvement in physicians' attitudes about dietary intervention, the authors conclude that both educational opportunities and physicians' practices warrant increased and more effective attention to nutrition. Finally, in light of recent trends and growing efforts to better prepare physicians to play a leading role in preventive care, the authors identify gaps in physicians' training and in research on physicians, preventive care, and applied nutrition.

A quantitatively scored cancer-risk assessment tool: its development and use.

Achievement of NIH and ACS goals for reduction in cancer mortality will require increased efforts directed at risk reduction and early detection in the general population. Primary care providers will play a major role. This paper describes the development and use of a quantitative cancer-risk appraisal tool designed to promote cancer prevention and screening and provide a framework for advancing education on these critical issues at all levels of medical training, to assist physicians in risk identification and patient counseling. The risk assessment questionnaire is close-ended and easily completed by the patient within 10 to 15 minutes. The IBM-compatible format permits easy quantitation by laser scanning and computer analysis. This program quantitates risks arising from interacting independent factors and estimates the effects of primary prevention interventions. Program output includes age- and sex-specific ACS screening guidelines and discussion of intensified screening measures in high-risk subjects.

Sexual misconduct in the practice of medicine. Council on Ethical and Judicial Affairs, American Medical Association

The American Medical Association's Council on Ethical and Judicial Affairs recently reviewed the ethical implications of sexual or romantic relationships between physicians and patients. The Council has concluded that (1) sexual contact or a romantic relationship concurrent with the physician-patient relationship is unethical; (2) sexual contact or a romantic relationship with a former patient may be unethical under certain circumstances; (3) education on the ethical issues involved in sexual misconduct should be included throughout all levels of medical training; and (4) in the case of sexual misconduct, reporting offending colleagues is especially important. (<i>JAMA</i>. 1991;266:2741-2745)

Sexual Misconduct in the Practice of Medicine

The American Medical Association's Council on Ethical and Judicial Affairs recently reviewed the ethical implications of sexual or romantic relationships between physicians and patients. The Council has concluded that (1) sexual contact or a romantic relationship concurrent with the physician-patient relationship is unethical; (2) sexual contact or a romantic relationship with a former patient may be unethical under certain circumstances; (3) education on the ethical issues involved in sexual misconduct should be included throughout all levels of medical training; and (4) in the case of sexual misconduct, reporting offending colleagues is especially important. ( JAMA . 1991;266:2741-2745)

Gender bias of Ohio physicians in the evaluation of the personal statements of residency applicants

Sexism has been documented at every level of medical training as well as in the community of practicing physicians. Although there is speculation in the literature about sexist attitudes and perceived sexual discrimination influencing a medical student's choice of specialty, there are few data on gender bias in the evaluation of residency candidates applying in different specialties. In 1989, the authors created six personal statements of interest in a residency, each from a different type of fictitious residency candidate (three men, three women, at three levels of medical school achievement) and mailed one or another of the statements, chosen at random, to the 2,478 board-certified Ohio physicians practicing in six specialties in which U.S. women in residencies were underrepresented (less than 12%) compared with the percentage of women in medical schools, and to the 3,586 board-certified Ohio physicians in another six specialties in which women in residencies were overrepresented (more than 38%). The physicians consistently rated the women candidates more favorably than they did the men candidates.

Students' perceptions of values emphasized in three medical schools.

The purpose of the study presented here was to assess medical students' perceptions of the weight given to scientific and humanistic values in their learning environment and to determine whether students' perceptions in a given school vary according to their level of medical training and personal characteristics. The study was conducted in 1979 via a mail questionnaire sent to a sample of 713 freshmen, juniors, and graduates from three U.S. medical schools; 82.2 percent responded. The results indicated that the students' perceptions of school values varied little according to the students' personal characteristics, such as sociodemographic and educational background, interests before medical training, and expected specialty choice. However, important differences were observed in students' perceptions of values emphasized to them at different schools. Preclinical and clinical students' perceptions of the importance given to scientific values were similar. As for humanistic values, significantly lower ratings were given by clinical students than preclinical students in two of the schools.

A hand-held decision-aid system designed for rural health workers

A great part of the world's population is cared for by rural health workers who are also collecting data for epidemiological studies. These workers have a low level of medical training and are working in a poor technical environment. At the request of an international humanitarian and medical organization (Médecins Sans Frontières), we have developed an integrated (hardware and software) system, TROPICAID, based on a hand-held computer and designed to increase rural health workers' efficiency. The software is easy to use and enables users to get information from an internal data base on 60 drugs. The decision-making module analyzes the patient's parameters (460 different symptoms are recognized) and indicates possible diagnoses (the system knows 210) and relevant treatments. In addition, the system facilitates the collection of medical data for elementary statistical analysis. The computer, which is lightweight (1.5 kg) and compact, runs on battery power for up to a week in normal use. The program which is written in Pascal and data are stored in high-capacity EPROMs. An early trial in Chad with Médecins sans Frontières has shown the value of such a project as well as a few weaknesses to be overcome.

Adolescent cancer patient and physician responses to a questionnaire on patient concerns.

In order to help physicians provide informational support to young patients with cancer, 63 adolescent cancer patients and 53 physicians completed self-administered questionnaires; 30 disease-related information items were included on the questionnaire. Although physicians and patients agreed on one-half of the items, they differed significantly on the others. Physician responses were not significantly related to the physicians' level of training, suggesting that education programs on this topic should be required at all levels of medical training. Psychiatrists may have a role to play in designing these programs.