Mike Tweed

Haemochromatosis as an endocrine cause of subfertility.

Haemochromatosis should be considered and iron studies performed when investigating endocrine causes of infertility Haemochromatosis is well established as a cause of infertility in both men and women, usually because iron deposition in the pituitary or the gonads leads to hypogonadism. As haemochromatosis is a fairly common disorder it should be considered when subfertility from an endocrine disorder is being investigated. We report on two related patients being investigated for subfertility in whom haemochromatosis was diagnosed only when one of them became diabetic. ### Case 1 A 32 year old man was referred to a tertiary referral centre for subfertility. He complained of failure of ejaculation and limited facial hair growth. Examination revealed female type and scanty axillary and pubic hair, soft testes (volume 8 …

Successful treatment of cepacia syndrome

a Departments of Paediatrics and Child Health, University of Otago, Wellington, Wellington Hospital, Capital and Coast Health, PO Box 7343, Wellington 6015, New Zealand b Queensland Paediatric Infectious Diseases Laboratory, Queensland Childrens Medical Research Institute, Royal Childrens Hospital, School of Medicine, University of Queensland, Brisbane, Australia c Department of Medicine, University of Otago, Wellington, Wellington Hospital, Capital and Coast Health, PO Box 7343, Wellington 6015, New Zealand

The face validity of a final professional clinical examination

To develop new methods of evaluating face validity in the context of a revised final professional examination for medical undergraduates, organized on three sites, over 2 days.

Developing the One‐Minute Preceptor

Background:  Learning from experienced doctors in real clinical settings is very important for medical students. However, the busy and at times unpredictable nature of clinical work means that clinical work must take priority over teaching. What clinicians want is to be able to offer quality learning experiences for students without significant disruption to their clinical work.

Observed consultation: confidence and accuracy of assessors

Judgments made by the assessors observing consultations are widely used in the assessment of medical students. The aim of this research was to study judgment accuracy and confidence and the relationship between these. Assessors watched recordings of consultations, scoring the students on: a checklist of items; attributes of consultation; a passmark scale and lastly their confidence in this last judgment. Then they were interviewed using stimulated recall to explain their rationale for scoring and confidence. Twenty-three staff assessors watched two consultations. Assessor confidence and accuracy were least for those student performances perceived near the passmark standard. The difference between confidence and accuracy, over-confidence, was greatest at this level, although at the extremes under-confidence was found. In the interviews the assessors were aware of a variety of factors that they perceived affected their scoring and confidence. As in other contexts confidence and accuracy vary and over-confidence increases the more difficult the judgments. However, this study also demonstrated under-confidence for less difficult judgments. The perception that more information would help, may improve confidence but not necessarily accuracy, so increasing over-confidence.

Legal vulnerability of assessment tools

Legal challenges relating to assessment results are increasing around the world. Until recently such challenges were not possible in the UK. With changes to the law, including the Human Rights Act, it is now possible for an Examining Body to have its assessment process challenged. Defending an assessment tool is potentially easy but not being prepared could lead to embarrassing defeat, with significant costs and damages to pay. Judgement may be made as to what constitutes appropriate methods of evaluating and the levels that assessments must attain. There are more questions than answers as to what will happen and who will be the true beneficiaries of potential and real challenges.

Disorganized junior doctors fail the MRCP (UK)

Career progression during undergraduate and early postgraduate years is currently determined by successfully passing examinations. Both academic factors (secondary school examination results, learning style and training opportunities) and non-academic factors (maturity, ethnic origin, gender and motivation) have been identified as predicting examination outcome. Few studies have examined organization skills. Disorganized medical students are more likely to perform poorly in end-of-year examinations but this observation has not been examined in junior doctors. This study asked whether organization skills relate to examination outcome amongst junior doctors taking the clinical Part II examination for the Membership of the Royal College of Physicians (Practical Assessment of Clinical Examination Skills). The study was conducted prospectively at four consecutive clinical courses that provided clinical teaching and practice to prepare trainees for the examination. Arrival time at registration for the course was the chosen surrogate for organization skills. Trainees were advised that they should arrive promptly at 8.00 a.m. for registration and it was explained that the course would start at 8.30 a.m. Recorded arrival times were compared with the pass lists published by the Royal College of Physicians. The mean arrival time was 8.17 a.m. A total of 81 doctors (53.3%) passed the examination with a mean arrival time of 8.14 a.m. However, 71 doctors failed the exam and arrived, on average, six minutes later than doctors who passed (p = 0.006). Better-prepared junior doctors were more likely to pass the final examination. Arriving on time represents a composite of several skills involved in the planning of appropriate travel arrangements and is therefore a valid marker of organization skills and preparation. This novel study has shown that good time-keeping skills are positively associated with examination outcome.

Low performing students have insightfulness when they reflect-in-action

Measuring appropriateness of certainty of responses in a progress test using descriptors authentic to practice as reflection‐in‐action builds on existing theories of self‐monitoring. Clinicians making decisions require the ability to accurately self‐monitor, including certainty of being correct. Inappropriate certainty could lead to medical error. Self‐assessment and certainty of assessment performance have been measured in a variety of ways. Previous work has shown that those with less experience are less accurate in self‐assessment, but such studies looked at self‐assessment using methods less authentic to clinical practice. This study investigates how correctness varies with certainty, allowing for experience and performance.

Decision-making bias in assessment: The effect of aggregating objective information and anecdote

Introduction: Assessment decisions increasingly rely on synthesis of information from a variety of sources. It is known that aggregation of information to make decisions is open to a number of biases. The aim of this research was to investigate bias, accuracy and confidence of assessment decision making. Methods: The participants were consultation skills assessors. A model for incremental information was developed with participants being shown results from purposefully selected, but authentic, data from the Universitys final summative 10-station Objective Structured Clinical Examination (OSCE). After each piece of information, participants gave a pass-fail decision and their confidence in that choice. Following the information from 10 OSCE stations the participants were given a discordant fictional anecdote and again participants gave a pass-fail decision and their confidence. Results: When there is overwhelming evidence to support a pass or fail, participants were not as confident as the data would support. Participants were less confident to make a fail decision than a pass. Despite considerable evidence from multiple results some participants altered decisions based on isolated contradictory information from an anecdote. Discussion: These findings are significant in understanding decision-making. Given equivalent levels of evidence, decision makers are less confident to fail than pass and less robust information can undermine more robust information.

A randomized controlled trial comparing instructions regarding unsafe response options in a MCQ examination

Background: Marking of multiple choice type examinations often just takes account of the correct responses. This may encourage guessing of incorrect and potentially unsafe responses. Ideally responses should contain a high proportion of correct, unsafe and the use of ‘don’t know’ response rather than incorrect. Aim: This study explored the effect of instructions on responses. Methods: Fourth- and fifth-year students sitting for an optional multiple choice examination were randomized to receive one of four instruction options: number-correct marking (the control group); alert to unsafe; mark deduction for unsafe; or correction for guessing. Results: A total of 210 students sat the test. For the fourth-year cohort, compared with the control group, being alerted to unsafe and mark deduction for unsafe or incorrect responses were associated with graduated increases in the use of ‘don’t know’ and reductions in incorrect responses. For the fifth-year cohort, there were no differences in responses between options. The fifth-year cohort, gave more correct, and fewer incorrect, unsafe and ‘don’t know’ responses. Conclusions: Both the year group and instructions had an effect. Being alerted to potentially unsafe responses, even when there is no mark deduction penalty, had an effect, although mark deduction still had the greatest effect. Assessment instructions may give subliminal messages that have important consequences.