Simulated Clinical Examination Research Articles

Pre-registration midwifery education: adapting infant feeding observed simulated clinical examinations

Digitally developed and virtually provided midwifery education has gathered momentum as a result of the COVID-19 pandemic. Preparing students for professional practice in a virtual environment creates challenges and creative opportunities for midwifery educators. Course designs and structures have been adapted to enable students to gain knowledge and experience of practicing in a virtual environment and approaches to assessment have also required adaptation. This article outlines how observed simulated clinical examinations were modified in conjunction with stakeholders from clinical practice and the breastfeeding community to ensure that they aligned with the local reality of virtual infant feeding support. Collaboration was required to ensure that the reality of student's experiences was captured in the assessment process. Challenges encountered included being sensitive to the fluidity of the clinical setting and ensuring that scenarios were relevant and created a sufficient challenge for students. Mitigating against students' concerns regarding virtual simulated clinical assessment should be incorporated into future adaptations of educational interventions and assessments.

Assessing Nephrology Fellows’ Skills in Communicating About Kidney Replacement Therapy and Kidney Biopsy: A Multicenter Clinical Simulation Study on Breaking Bad News

Interpersonal communication skills and professionalism competencies are difficult to assess among nephrology trainees. We developed a formative "Breaking Bad News" simulation and implemented a study in which nephrology fellows were assessed with regard to their skills in providing counseling to simulated patients confronting the need for kidney replacement therapy (KRT) or kidney biopsy. Observational study of communication competency in the setting of preparing for KRT for kidney failure, for KRT for acute kidney injury (AKI), or for kidney biopsy. 58 first- and second-year nephrology fellows assessed during 71 clinical evaluation sessions at 8 training programs who participated in an objective structured clinical examination of simulated patients in 2017 and2018. Fellowship training year and clinical scenario. Primary outcome was the composite score for the "overall rating" item on the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS), as assessed by simulated patients. Secondary outcomes were the score for EEC-GRS "overall rating" item for each scenario, score< 3 for any EEC-GRS item, Mini-Clinical Examination Exercise (Mini-CEX) score< 3 on at least 1 item (as assessed by faculty), and faculty and fellow satisfaction with simulation exercise (via a survey they completed). Nonparametric tests of hypothesis comparing performance by fellowship year (primary goal) and scenario. Composite scores for EEC-GRS overall rating item were not significantly different between fellowship years (P= 0.2). Only 4 of 71 fellow evaluations had an unsatisfactory score for the EEC-GRS overall rating item on any scenario. On Mini-CEX, 17% scored< 3 on at least 1 item in the kidney failure scenario; 37% and 53% scored< 3 on at least 1 item in the AKI and kidney biopsy scenarios, respectively. In the survey, 96% of fellows and 100% of faculty reported the learning objectives were met and rated the experience good or better in 3 survey rating questions. Relatively brief time for interactions; limited familiarity with and training of simulated patients in use of EEC-GRS. The fellows scored highly on the EEC-GRS regardless of their training year, suggesting interpersonal communication competency is achieved early in training. The fellows did better with the kidney failure scenario than with the AKI and kidney biopsy scenarios. Structured simulated clinical examinations may be useful to inform curricular choices and may be a valuable assessment tool for communication and professionalism.

Utilizing an Objective Simulated Clinical Examination (OSCE) for orofacial disorders.

Journal of Dental EducationVolume 85, Issue S1 p. 1022-1023 ADVANCING THROUGH INNOVATION Utilizing an Objective Simulated Clinical Examination (OSCE) for orofacial disorders Eric T. Stoopler DMD, FDSRCS, FDSRCPS, Corresponding Author Eric T. Stoopler DMD, FDSRCS, FDSRCPS [email protected] Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA Correspondence Eric T. Stoopler, DMD, FDSRCS, FDSRCPS, Penn Dental Medicine, 240 South 40th Street, Room 206, Philadelphia, PA 19104, USA. Email: [email protected]Search for more papers by this authorArthur S. Kuperstein DDS, Arthur S. Kuperstein DDS Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USASearch for more papers by this authorThomas R. Berardi DDS, Thomas R. Berardi DDS Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USASearch for more papers by this authorThomas P. Sollecito DMD, FDS RCSEd, Thomas P. Sollecito DMD, FDS RCSEd Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USASearch for more papers by this author Eric T. Stoopler DMD, FDSRCS, FDSRCPS, Corresponding Author Eric T. Stoopler DMD, FDSRCS, FDSRCPS [email protected] Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA Correspondence Eric T. Stoopler, DMD, FDSRCS, FDSRCPS, Penn Dental Medicine, 240 South 40th Street, Room 206, Philadelphia, PA 19104, USA. Email: [email protected]Search for more papers by this authorArthur S. Kuperstein DDS, Arthur S. Kuperstein DDS Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USASearch for more papers by this authorThomas R. Berardi DDS, Thomas R. Berardi DDS Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USASearch for more papers by this authorThomas P. Sollecito DMD, FDS RCSEd, Thomas P. Sollecito DMD, FDS RCSEd Department of Oral Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USASearch for more papers by this author First published: 12 August 2020 https://doi.org/10.1002/jdd.12383Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume85, IssueS1Supplement: Advancing Through Innovation in a Challenging TimeJune 2021Pages 1022-1023 This article also appears in:Advancing Through Innovation in a Challenging Time RelatedInformation

Utilizing an objective simulated clinical examination (OSCE) for temporomandibular disorder.

Utilizing an objective simulated clinical examination (OSCE) for temporomandibular disorder.

Enhancing Strabismus Education through Interactive Learning Multimedia

The objective of our project was to create an interactive online educational module that integrates biomechanics of the eye with its underlying anatomy to allow for a comprehensive understanding of pediatric strabismus and its clinical detection to prevent amblyopia.Amblyopia is the leading cause of monocular vision loss in the pediatric population, affecting 3–5% of children. Untreated, it leads to irreversible visual impairment in an otherwise structurally normal eye and can have significant effects on quality of life that impact self‐esteem and restrict career opportunities due to loss of stereopsis. Majority of cases are caused by strabismus, a condition resulting in the ocular misalignment of the eye. Early intervention significantly improves vision outcomes and psychosocial well‐being of the patient, however requires prompt and skilled detection. The pediatric eye examination can be inherently challenging, particularly considering the low emphasis on ophthalmology teaching in medical school curricula. Primary care residents and undergraduate medical student trainees often report low levels of comfort performing screening eye examinations and managing common pediatric ophthalmological presentations. Integration of open educational resources such as interactive clinical skills modules can effectively advance ophthalmology education and promote prompt detection of pediatric strabismus, with the goal of mitigating serious ophthalmic complications and improving overall patient care.To effectively address these educational challenges, we have developed an innovative online module that correlates ocular anatomy to biomechanical mechanisms, and provides practical guidelines to clinical examination. The module focuses on the pediatric eye examination, evaluating for amblyopia &amp; strabismus, and was created through an international collaboration with experts in anatomy, education, and neuro‐ophthalmology to optimize content delivery and integrate clinical relevance. It offers a variety of interactive activities to engage student learning and concludes with a set of virtual cases entailing simulated clinical examination to assess acquired knowledge. Critical feedback will be collected using a student experience survey at the beginning and end of the module to solicit response regarding effectiveness of content delivery, preference of educational media, and comfort conducting a strabismus clinical examination.This international effort aims to significantly improve confidence performing clinical examination, guide prompt amblyopia detection in the pediatric population, and prevent development of its irrevocable complications.

Biomechanical contribution of the alar ligaments to upper cervical stability

Acute and chronic whiplash-associated disorders pose a significant healthcare burden due to chronic pain, which is associated with upper cervical instability resulting from ligamentous injury. No standard measure exists for diagnosing alar ligament injury and imaging findings vary widely. Multiple physical examination maneuvers are used to diagnose alar ligament injury including the C2 Spinous Kick, Flexion-Rotation, and Bending-Rotation tests. The objective of the current study was to determine the mechanical contribution of the alar ligaments to upper cervical stability and quantify the biomechanical changes seen during simulated clinical examinations after alar ligament injury. Eight cadaveric C0-C3 specimens were evaluated using a robotic testing system. Range of motion and moment at the end of intact specimen replay were the primary outcomes. Clinical examinations were simulated by rotation through two axes as performed during physical examination. Intact, unilateral and bilateral alar ligament injury states were tested. Unilateral alar ligament injury led to significant increases in lateral bending (12.0 ± 7.2%, p < 0.05), axial rotation (4.1 ± 2.4%, p < 0.05), and flexion-extension (5.3 ± 4.3%, p < 0.05) compared with intact specimens. The alar ligaments also contributed to resistance to intact motion in extension (13.4 ± 6.6%, p < 0.05), flexion (4.4 ± 2.2%, p < 0.05), axial rotation (19.3 ± 2.7%, p < 0.05), and lateral bending (16.0 ± 2.8%, p < 0.05). The C2 Spinous Kick Test showed the largest percentage change (−23.0 ± 14.8%), and the Bending-Rotation Test towards the side of injury significantly increased axial rotation by the largest absolute magnitude (5.5° ± 5.1°). Overall, quantifiable changes to motion measured during simulated physical examinations were found, but the ability of a clinician to feel these changes remains unknown.

Nonverbal Affiliation by Physician Assistant Students during Simulated Clinical Examinations: Genotypic Effects

In the relationship between patients and health care providers, the use of nonverbal affiliative behaviors—including smiling, facial expressiveness, and a lack of dominance—is associated with multiple benefits to patient satisfaction, compliance, and health. However, little is known about what accounts for variance in providers’ tendencies to enact nonverbal affiliative behaviors during routine patient encounters. The present exploratory study examines nonverbal affiliative behaviors by physician assistant students in interactions with standardized patients. Each student conducted three clinical interviews over a 6-month period, each of which was coded for a cadre of nonverbal affiliative behaviors. Students also provided saliva samples for genotyping six single-nucleotide polymorphisms on the oxytocin receptor gene (OXTR) that are linked empirically to affiliation and other prosocial behaviors. Consistent with recent research, this study adopted a cumulative risk approach wherein students were scored for their number of risk alleles on the single-nucleotide polymorphisms. Results indicated that cumulative risk on the oxytocin receptor gene significantly predicted four out of five nonverbal affiliative behaviors.

Is it time to rethink the MCCQE Part II?

Formed in 1912, the Medical Council of Canada (MCC) was given a “legislated mandate to assure patients that their doctors, wherever they are in Canada and whatever their medical specialty, meet the same demanding, consistent standards.” This was a time of variable medical training practices, and the new Licentiate of the Medical Council of Canada (LMCC) designation awarded to candidates who completed the appropriate requirements represented a step towards a more standardized, higher quality, and safer medical system. Prior to 1954, those awarded the LMCC designation, following successful completion of the MCC Qualifying Exam (MCCQE), were typically awarded a provincial license to practice medicine. Following 1954, the LMCC required successful completion of the MCCQE, as well as one year of additional training prior to registration. This ultimately became the basis for the rotating internship year, after which a provincial license would be granted to allow practice as a “General Practitioner” or “GP.” In the 1980s and early 1990s, however, provincial licensing bodies began moving towards requiring a minimum of two years of post-graduate training, and often required certification through one of the national colleges. This was followed by changes to the LMCC and the introduction of the MCCQE Part II – a simulated clinical examination taken after a minimum of one year of postgraduate residency training.

An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 2

Background: Recent biomechanical studies have demonstrated that an extra-articular lateral knee structure, most recently referred to as the anterolateral ligament (ALL), contributes to overall rotational stability of the knee. However, the effect of anatomic ALL reconstruction (ALLR) in the setting of anterior cruciate ligament (ACL) reconstruction (ACLR) has not been biomechanically investigated or validated. Purpose/Hypothesis: The purpose of this study was to investigate the biomechanical function of anatomic ALLR in the setting of a combined ACL and ALL injury. More specifically, this investigation focused on the effect of ALLR on resultant rotatory stability when performed in combination with concomitant ACLR. It was hypothesized that ALLR would significantly reduce internal rotation and axial plane translation laxity during a simulated pivot-shift test compared with isolated ACLR. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen cadaveric knees were evaluated with a 6 degrees of freedom robotic system. Knee kinematics were evaluated with simulated clinical examinations including a simulated pivot-shift test consisting of coupled 10-N·m valgus and 5-N·m internal rotation torques, a 5-N·m internal rotation torque, and an 88-N anterior tibial load. Kinematic differences between ACLR with an intact ALL, ACLR with ALLR, and ACLR with a deficient ALL were compared with the intact state. Single-bundle ACLR tunnels and ALLR tunnels were placed anatomically according to previous quantitative anatomic attachment descriptions. Results: Combined anatomic ALLR and ACLR significantly improved the rotatory stability of the knee compared with isolated ACLR in the face of a concurrent ALL deficiency. During a simulated pivot-shift test, ALLR significantly reduced internal rotation and axial plane tibial translation when compared with ACLR with an ALL deficiency. Isolated ACLR for the treatment of a combined ACL and ALL injury was not able to restore stability of the knee, resulting in a significant increase in residual internal rotation laxity. ALLR did not affect anterior tibial translation; no significant differences were observed between the varying ALL conditions with ACLR except between ACLR with an intact ALL and ACLR with a deficient ALL at 0° of flexion. Conclusion: In the face of a combined ACL and ALL deficiency, concurrent ACLR and ALLR significantly improved the rotatory stability of the knee compared with solely reconstructing the ACL. Clinical Relevance: Significant increases in residual internal rotation and laxity during the pivot-shift test may exist in both acute and chronic settings of an ACL deficiency and in patients treated with isolated ACLR for a combined ACL and ALL deficiency. For this subset of patients, surgical treatment of the ALL, in addition to ACLR, should be considered to restore knee stability.

An In Vitro Robotic Assessment of the Anterolateral Ligament, Part 1

Background: Recent investigations have described the structural and functional behavior of the anterolateral ligament (ALL) of the knee through pull-apart and isolated sectioning studies. However, the secondary stabilizing role of the ALL in the setting of a complete anterior cruciate ligament (ACL) tear has not been fully defined for common simulated clinical examinations, such as the pivot-shift, anterior drawer, and internal rotation tests. Hypothesis: Combined sectioning of the ALL and ACL would lead to increased internal rotation and increased axial plane translation during a pivot-shift test when compared with isolated sectioning of the ACL. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen human cadaveric knees were subjected to a simulated pivot-shift test with coupled 10-N·m valgus and 5-N·m internal rotation torques from 0° to 60° of knee flexion and a 5-N·m internal rotation torque and an 88-N anterior tibial load, both from 0° to 120° of knee flexion via a 6 degrees of freedom robotic system. Kinematic changes were measured and compared with the intact state for isolated sectioning of the ACL and combined sectioning of the ACL and ALL. Results: Combined sectioning of the ACL and ALL resulted in a significant increase in axial plane tibial translation during a simulated pivot shift at 0°, 15°, 30°, and 60° of knee flexion and a significant increase in internal rotation at 0°, 15°, 30°, 45°, 60°, 75°, 90°, 105°, and 120° when compared with the intact and ACL-deficient states. Based on the model results, ALL sectioning resulted in an additional 2.1 mm (95% CI, 1.4-2.9 mm; P < .001) of axial plane translation during the pivot shift when compared with ACL-only sectioning, when pooling evidence over all flexion angles. Likewise, when subjected to IR torque, the ACL+ALL-deficient state resulted in an additional 3.2° of internal rotation (95% CI, 2.4°-4.1°; P < .001) versus the intact state, and the additional sectioning of the ALL increased internal rotation by 2.7° (95% CI, 1.8°-3.6°; P < .001) versus the ACL-deficient state. Conclusion: The results of this study confirm the ALL as an important lateral knee structure that provides rotatory stability to the knee. Specifically, the ALL was a significant secondary stabilizer throughout flexion during an applied internal rotation torque and simulated pivot-shift test in the context of an ACL-deficient knee. Clinical Relevance: Residual internal rotation and a positive pivot shift after ACL reconstruction may be attributed to ALL injury. For these patients, surgical treatment of an ALL tear may be considered.

Non-medical prescribing assessment – An evaluation of a nationally agreed multi method approach

In the United Kingdom, legislation permits nurses and allied health professionals to prescribe for patients within their care. Preparation for this role includes learning, teaching and assessment that is embedded in practice, supervised by a designated medical practitioner (DMP) and evidenced in a reflective learning in practice portfolio. AimThe objectives were to explore; (1) which assessment in the practice portfolio was ranked most valuable in terms of achieving safe, effective prescribing practice and, (2) whether a practice based assessment (SDEP) was an acceptable alternative to an Observed Simulated Clinical Examination (OSCE). MethodsOnline surveys were conducted and follow up semi structured telephone interviews were conducted across 5 universities in Scotland with students, DMPs and line managers. ResultsStudents ranked the learning log most valuable and DMPs and line managers ranked the SDEP most valuable. Survey and follow up interviews suggested that the portfolio provided the opportunity to develop prescribing skills and knowledge relevant to their specific clinical speciality. There was agreement amongst all participants that clinical assessment in the practice portfolio effectively enable non-medical prescribing students to evidence prescribing competence. SummaryThe novel use of the SDEP and reflective summary offers a viable alternative to an OSCE and was viewed as one of the most valued components of the assessment strategy.

Effectiveness of a simulated clinical examination in the assessment of the clinical competencies of entry-level trainees in a family medicine residency programme

Clinical competence is a multidimensional concept and encompasses a variety of skills including procedural, problem-solving and clinical judgement. The initial stages of postgraduate medical training are believed to be a particularly important time for the development of clinical skill competencies. This study reports on an evaluation of a Simulated Clinical Examination (SCE) method as a means of assessing the clinical skill competencies of entry-level family medicine residents. Two entering cohorts of PGY1 family medicine residents (N = 35) participated in a SCE encompassing realistic clinical encounters with standardised patients (SPs). Residents were asked to complete pre- and post-evaluation surveys, and both faculty and residents were invited to participate in separate focus groups. The SCE was perceived as a useful method during the early phases of postgraduate training for assessing clinical skill competencies, providing constructive feedback to residents and enhancing self-awareness and confidence. The SCE also appeared to be useful in fostering confidence in interviewing and diagnostic reasoning, however self-reported confidence in the ability to perform clinical skill tasks related to history taking, physical examination and differential diagnosis was not associated with observed performance in these areas. The SCE was an effective technique for benchmarking skill performance, however further research is required to evaluate the effect of this on the self-assessment abilities of trainees over the course of postgraduate medical education.

A Biomechanical Comparison of 2 Femoral Fixation Techniques for Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients: Over-the-Top Fixation Versus Transphyseal Technique

The purpose of this study was to compare knee kinematics and in situ forces of the graft between 2 femoral fixation techniques of anterior cruciate ligament (ACL) reconstruction: the over-the-top (OTT) fixation and transphyseal (TP) techniques. ACL reconstruction in skeletally immature patients is a challenging procedure. Regarding the femoral fixation techniques, 2 methods are commonly used: the OTT fixation and TP techniques. Ten cadaveric knees (mean age, 57 years; range, 48 to 65 years) were tested with the robotic/universal force-moment sensor system by use of (1) an 89-N anterior tibial load at full extension and 15°, 30°, 60°, and 90° of knee flexion and (2) a combined 7-Nm valgus torque and 5-Nm internal tibial rotation torque at 15° and 30° of knee flexion. Both OTT and TP ACL reconstruction techniques closely restored the intact knee kinematics and had a significant reduction in anterior tibial translation under an anterior tibial load and in coupled anterior tibial translation under a combined rotatory load when compared with an ACL-deficient knee. When both ACL reconstruction techniques were compared, the only difference found was that the in situ force of the ACL graft reconstructed with the OTT technique in response to a combined rotatory load at 30° of flexion was significantly lower than the ACL graft reconstructed with the TP technique (5.3 ± 3.3 N and 10.7 ± 6.0 N, respectively; P = .013). This time 0 testing showed that both ACL reconstruction techniques, OTT and TP, can reproduce the kinematics of the intact knee in response to an anterior tibial load and a combined rotatory load. Both femoral fixation techniques exhibited comparable time 0 kinematics when subjected to simulated clinical examination loading conditions.

Evaluation of the usefulness of simulated clinical examination in family-medicine residency program

Background: This study reports on an evaluation of the usefulness of the Simulated Clinical Examination (SCE) method as a means of assessing the clinical-skill competencies of entering Postgraduate year 1 (PGY1) family-medicine residents.Methods: PGY1 family-medicine residents participated in a SCE encompassing clinical encounters with standardized patients. Residents were asked to complete pre-evaluation and post-evaluation surveys, and faculty and residents participated in separate focus groups.Results: The SCE was perceived as a useful method during the early phases of postgraduate training for assessing clinical-skill competencies, providing constructive feedback to residents, enhancing self-awareness, and enhancing confidence.Conclusions: This exploratory study suggests that the SCE, as an assessment method, can have beneficial effects on learning and the fostering of clinical-skill competencies during postgraduate training.

Developing performance-based medical school assessment programs in resource-limited environments

While the use of performance-based assessments in medical schools is widespread, there are unique issues associated with developing and establishing simulated clinical examinations when resources are limited. The faculty at the National University of Cuyo (NUC) in Mendoza, Argentina, has successfully implemented an OSCE as part of the medical school graduation requirements. This paper provides an overview of the issues faced by NUC faculty in setting up a standardized patient (SP)-based assessment with only limited resources, and contrasts their experiences with those of other groups, including certification and licensure bodies who have implemented similar types of assessments. Despite their novelty and a lack of technological, staffing, and budgetary resources, with adequate planning, an emphasis on faculty involvement, quality case development, local SP recruitment and training activities, educational programs focused on assessment, and flexibility in creating a physical space to conduct the exam, an effective program for assessing the clinical skills of medical students can be realized.

Stress and strain in the anterior band of the inferior glenohumeral ligament during a simulated clinical examination

The objective of this research was to predict, with a finite-element model, the stress and strain fields in the anterior band of the inferior glenohumeral ligament (AB-IGHL) during application of an anterior load with the humerus abducted. The stress and strain in the AB-IGHL were determined during a simulated simple translation test of a single intact shoulder. A 6-degree-of-freedom magnetic tracking system was used to measure the kinematics of the humerus with respect to the scapula. A clinician applied an anterior load to the humerus until a manual maximum was achieved at 60 degrees of glenohumeral abduction and 0 degrees of flexion/extension and external rotation. For the computational analysis, the experimentally measured joint kinematics were used to prescribe the motion of the humerus with respect to the scapula, whereas the material properties of the AB-IGHL were based on published experimental data. The geometry of the AB-IGHL, humerus, and scapula was acquired by use of a volumetric computed tomography scan, which was used to define the reference configuration of the AB-IGHL. Strains reached 12% along the inferior edge and 15% near the scapular insertion site at the position of maximum anterior translation. During this motion, the AB-IGHL wrapped around the humerus and transferred load to the bone via contact. Predicted values for von Mises stress in the ligament reached 4.3 MPa at the point of contact with the humeral head and 6.4 MPa near the scapular insertion site. A comparison of these results to the literature suggests that the computational approach provided reasonable predictions of fiber strain in the AB-IGHL when specimen-specific geometry and kinematics with average material properties were used. The complex stress and strain distribution throughout the AB-IGHL suggests that the continuous nature of the glenohumeral capsule should be considered in biomechanical analyses. In the future, this combined experimental and computational approach will be used for subject-specific studies of capsular function and could provide quantitative data to help surgeons improve methods for the diagnosis and treatment of glenohumeral instability.

Comparisons of National Board Part II and NERB's Written Examination for Outcomes and Redundancy

The purpose of this study was to compare students' in-school academic performance with their scores on the North East Regional Board (NERB) of Dental Examiners' Dental Simulated Clinical Examination (DSCE; written) and the written examination given by the National Board of Dental Examiners, Part II (NBDE Part II). A second purpose was to evaluate whether requiring the DSCE in addition to the NBDE II is of benefit in assessing the qualifications of candidates for licensure. Results on the first attempt at passing the two examinations were compared for 836 graduates (1994-2002) of one dental school. Mean scores on the examinations and mean grade point average (GPA) of those who passed the two examinations did not differ. Mean GPAs of those who failed the two examinations also were not significantly different. Scores on the two exams and GPA significantly correlated with each other. Correlation coefficients were higher between GPA and scores on the NBDE II than between GPA and scores on the DSCE. The failure rates on first attempts were 6 percent on the DSCE and 7 percent on the NBDE II. The results of this study suggest that the DSCE does not materially assist in the licensure decision for candidates who passed the NBDE Part II, as the results on the two exams are very similar.

Use of discriminant and regression analyses to modify a clinical certification board examination

The National Dental Examining Board of Canada (NDEB) conducts mandatory, high stakes, pass/fail, certification examinations for dental licensure. One of these examinations was a seven-part, simulated clinical examination in which candidates were required to perform procedures on typodonts. These requirements were two intracoronal and two extracoronal preparations, an amalgam restoration, a provisional crown, and a diagnostic wax-up. Feedback from candidates and examiners indicated that one or more of the requirements may not have been contributing effectively to the overall evaluation of candidates. The NDEB's Clinical Examination Committee therefore requested that an in-depth statistical analysis be performed to identify potential areas of concern and to provide a basis for modifying the examinations. The results of two examination sessions with a total of 168 candidates were subjected to both a discriminant and a logistic regression analysis. Every candidate had results for each of the seven requirements, and no candidate participated in both sessions of the examination. The discriminant analysis revealed that six of the seven requirements could be used to reliably assign examinees according to their true pass/fail classifications. Stepwise discriminant analysis resulted in a 98.81 percent classification success rate with a corresponding 2.50 percent false-positive classification error rate. The logistic regression analysis showed that five components correctly predicted 99.40 percent with a 1.25 percent false-positive rate. The Clinical Examination Committee concluded that one requirement (diagnostic wax-up) should be eliminated and that a second requirement (PFM preparation) be significantly modified and reevaluated. This study demonstrates the usefulness of statistical methods in the analysis and modification of a clinical certification board examination.