Robert S. Wigton

The effect of feedback in learning clinical diagnosis

There is evidence that students who are given information about how they appear to weight information in reaching a judgment can learn to make judgments more accurately. In teaching medical diagnosis, the present authors used a microcomputer system to generate simulated cases and then calculate the relationship between the data presented and the students diagnosis. Students who were given feedback comparing their apparent weighting of clinical information with the correct weighting learned to diagnose urinary tract infection more accurately than control students who received feedback only on the outcome of their diagnosis.

Procedural skills training in the internal medicine residency

To determine whether there was agreement on a core of procedural skills that all internal medicine residents should be able to perform, faculty members and residents at the University of Pennsylvania and the University of Nebraska were surveyed regarding 72 procedures. Nineteen procedures were indicated by 90 percent or more of the respondents as those that should be learned by the graduates. In response to a second survey, many senior residents said they did not feel competent to perform these 19 procedures, and many did not recall that their performance on procedures had been evaluated. Thus, despite any regional or institutional influences, there was agreement on a core of procedural skills that should be required of all physicians completing the general internal medicine residency. It is important that training programs assess whether or not the procedures they consider essential are being mastered by their residents.

A controlled trial of an interactive, web-based virtual reality program for teaching physical diagnosis skills to medical students.

Multimedia instruction offers many potential advantages over traditional methods of instruction. Multimedia programs can interact with the learner, use graphic images, sound, and video, and keep track of progress. Students complete programs at their own pace while accessing material both at school and at home. Multimedia instruction can provide an interactive alternative to lectures and textbooks by quizzing the student over concepts as they are presented and requiring that the student think about the material before proceeding. While several studies have found that multimedia instruction can be more efficient by reducing instructor and classroom time, few have been able to show an increase in learning when compared with traditional methods of instruction. Santer and colleagues compared a multimedia textbook with a lecture presentation on the same material and found an increase in the post-test scores of the multimedia group, but no difference when they compared the multimedia group with a group using a printed textbook. Studies comparing multimedia and traditional approaches to learning in the areas of psychology and computer science instruction suggest an improvement in students’ performances using the multimedia versions. Thus, there is a need for well-designed studies to determine whether multimedia instruction more effectively facilitates students’ learning—including medical students’ learning—than do traditional methods. Multimedia instruction is particularly well suited to help students learn physical diagnosis. Sound, pictures, and movies augment the learning of examination skills and diagnosis findings by allowing students to hear heart and lung sounds, watch videos of physical examination procedures, and see more pictures of pathologic findings than can be included in a textbook or lecture. These visual and audio aids should increase students’ recognition of these findings when encountered in patients. We wished to test whether a Web-based multimedia program using interactive learning and virtual reality would be more efficient and effective than traditional print-based self-study by medical students. To accomplish this, we designed a course on physical examination of the eye and ear. Using this material, we conducted a controlled study of first-year medical students to determine whether having students use a multimedia version of the course resulted in a change in the time spent with the material and an increase in knowledge gained when compared with having students study a printed version of the same material.

Training Internists in Procedural Skills

The procedural skills of internists have been scrutinized recently because of concern for quality of care and because of economic and liability issues. The findings of recent surveys of program directors and practicing internists about procedural skills are reviewed. The results of these surveys in relation to the American Board of Internal Medicines (ABIM) new training requirements and New York States new policy requiring credentialing of residents in training are also discussed. Surveys show that internists do a large number and variety of procedures, that the number of procedures varies with the nature and location of practice, and that internists who more recently completed training do more procedures. Many graduates do not master the procedures their program directors think they should, and many learn procedures, often without supervision, after they have entered practice. The ABIM has recently ruled that residents must have documented experience and competence in specific core procedures to become eligible for certification. Also, New York State, in the wake of the Libby Zion case, now requires that all residents be credentialed in the procedures they do during training. Programs in internal medicine need to decide which procedures their residents will master and assure that their residents receive the training and testing necessary for competency and for formal certification of mastery in each procedure. Programs may restructure rotations to assure adequate experience. In the new era of accountability, certification of training and of competence in procedural skills will be an important function of training programs.

Teaching old dogs new tricks: Using cognitive feedback to improve physicians’ diagnostic judgments on simulated cases

No abstract available.

The Effects of Student Personal Characteristics on the Evaluation of Clinical Performance.

Faculty evaluations of videotaped student case presentations were used to determine whether personal characteristics of students influence the evaluation of their clinical ability. Five first-year medical students were coached to present each of five prepared case presentations which varied significantly in content and organization. Fifteen experienced faculty teachers evaluated the presentations. They viewed the presentations in a sequence that allowed comparison of grades given to the same case presented by different students. Results show the ranking given each presentation depended as much on which student was doing the presentation as the content of the presentation. Grades given identical videotaped presentations by different faculty members showed little correlation. This study shows that the evaluation of clinical competence based on the student case presentation can be significantly influenced by the personal characteristics of the students and that faculty members do not appear to share common standards for evaluating case presentations.

A Method for Selecting which Procedural Skills Should Be Learned by Internal Medicine Residents.

Despite a need for better documentation of training in procedural skills in internal medicine, there is no general agreement regarding which skills should be required. This paper describes a method for selecting which procedural skills should be mastered by medicine residents. Seventy-two skills were collected from faculty suggestions, review of the literature, and hospital privilege request forms. Residents and faculty at the University of Nebraska College of Medicine were asked to select from the list those skills which should be mastered by all residents completing the three-year general internal medicine residency. At least 80 percent of the 107 respondents agreed on 30 skills that should be learned by all residents, but there was significant disagreement regarding the need for some of the skills. In a second survey, at least one-fourth of the 16 senior residents did not feel competent to perform 13 of the 30 skills, indicating areas which require scrutiny.

The effects of proficiency and bias on residents' interpretation of the microscopic urinalysis

Objective . This study aims to determine whether residents are influenced by clinical information when interpreting microscopic urinalysis (UA) and estimating the probability of a urinary tract infection (UTI), and to determine the accuracy and reliability of UA readings. Design . Residents estimated the UA white blood cell count and the probability of a UTI in vignettes using a fractional factorial design, varying symptoms, gender, and the white blood cell count on preprepared urine slides. Results . Individual-level results indicated a clinical information bias and poor accuracy. Seventeen of 38 residents increased the white blood cell count in response to female gender; 14 increased the white blood cell count in response to UTI symptoms. Forty-nine percent of the readings were inaccurate; agreement ranged from 50% to 67% for white and red blood cells and bacteria. Conclusion . Many residents gave inaccurate UA readings, and many readings varied with clinical information. A significant portion of residents needs assistance in objectively and accurately interpreting the UA.

An innovative faculty appointment system at the University of Nebraska.

No abstract available.