Sylvain Coderre

Diagnostic reasoning strategies and diagnostic success.

Purpose Cognitive psychology research supports the notion that experts use mental frameworks or ‘schemes’, both to organize knowledge in memory and to solve clinical problems. The central purpose of this study was to determine the relationship between problem‐solving strategies and the likelihood of diagnostic success.

Treatment of Sclerosing Mesenteritis with Corticosteroids and Azathioprine

Sclerosing (idiopathic) mesenteritis is a rare disease that may present with abdominal pain or bowel obstruction. A 21-year-old man was diagnosed with sclerosing mesenteritis, and treated with a partial ileal resection and defunctioning ileostomy. He was subsequently started on corticosteroids and azathioprine. Five months later, at the time of ileostomy reversal, he was disease-free. The diagnosis and management of this disease are discussed.

Can standardized patients replace physicians as OSCE examiners

BackgroundTo reduce inter-rater variability in evaluations and the demand on physician time, standardized patients (SP) are being used as examiners in OSCEs. There is concern that SP have insufficient training to provide valid evaluation of student competence and/or provide feedback on clinical skills. It is also unknown if SP ratings predict student competence in other areas. The objectives of this study were: to examine student attitudes towards SP examiners; to compare SP and physician evaluations of competence; and to compare predictive validity of these scores, using performance on the multiple choice questions examination (MCQE) as the outcome variable.MethodsThis was a cross-sectional study of third-year medical students undergoing an OSCE during the Internal Medicine clerkship rotation. Fifty-two students rotated through 8 stations (6 physician, 2 SP examiners). Statistical tests used were Pearsons correlation coefficient, two-sample t-test, effect size calculation, and multiple linear regression.ResultsMost students reported that SP stations were less stressful, that SP were as good as physicians in giving feedback, and that SP were sufficiently trained to judge clinical skills. SP scored students higher than physicians (mean 90.4% +/- 8.9 vs. 82.2% +/- 3.7, d = 1.5, p < 0.001) and there was a weak correlation between the SP and physician scores (coefficient 0.4, p = 0.003). Physician scores were predictive of summative MCQE scores (regression coefficient = 0.88 [0.15, 1.61], P = 0.019) but there was no relationship between SP scores and summative MCQE scores (regression coefficient = -0.23, P = 0.133).ConclusionThese results suggest that SP examiners are acceptable to medical students, SP rate students higher than physicians and, unlike physician scores, SP scores are not related to other measures of competence.

The impact of two multiple-choice question formats on the problem-solving strategies used by novices and experts

BackgroundPencil-and-paper examination formats, and specifically the standard, five-option multiple-choice question, have often been questioned as a means for assessing higher-order clinical reasoning or problem solving. This study firstly investigated whether two paper formats with differing number of alternatives (standard five-option and extended-matching questions) can test problem-solving abilities. Secondly, the impact of the alternatives number on psychometrics and problem-solving strategies was examined.MethodsThink-aloud protocols were collected to determine the problem-solving strategy used by experts and non-experts in answering Gastroenterology questions, across the two pencil-and-paper formats.ResultsThe two formats demonstrated equal ability in testing problem-solving abilities, while the number of alternatives did not significantly impact psychometrics or problem-solving strategies utilized.ConclusionsThese results support the notion that well-constructed multiple-choice questions can in fact test higher order clinical reasoning. Furthermore, it can be concluded that in testing clinical reasoning, the question stem, or content, remains more important than the number of alternatives.

Twelve tips for blueprinting

Background: Content validity is a requirement of every evaluation and is achieved when the evaluation content is congruent with the learning objectives and the learning experiences. Congruence between these three pillars of education can be facilitated by blueprinting. Aims: Here we describe an efficient process for creating a blueprint and explain how to use this tool to guide all aspects of course creation and evaluation. Conclusions: A well constructed blueprint is a valuable tool for medical educators. In addition to validating evaluation content, a blueprint can also be used to guide selection of curricular content and learning experiences.

Teaching in small portions dispersed over time enhances long-term knowledge retention

Background: A primary goal of education is to promote long-term knowledge storage and retrieval. Objective: A prospective interventional study design was used to investigate our research question: Does a dispersed curriculum promote better short- and long-term retention over a massed course? Methods: Participants included 20 gastroenterology residents from the University of Calgary (N = 10) and University of Toronto (N = 10). Participants completed a baseline test of nutrition knowledge. The nutrition course was imparted to University of Calgary residents for 4 h occurring 1 h weekly over 4 consecutive weeks: dispersed delivery (DD). At the University of Toronto the course was taught in one 4h academic half-day: massed delivery (MD). Post-curriculum tests were administered at 1 week and 3 months to assess knowledge retention. Results: The baseline scores were 46.39 ± 6.14% and 53.75 ± 10.69% in the DD and MD groups, respectively. The 1 week post-test scores for the DD and MD groups were 81.67 ± 8.57%, p < 0.001 and 78.75 ± 4.43, p < 0.001 which was significantly higher than baseline. The 3-month score was significantly higher in the DD group, but not in the MD group (65.28 ± 9.88%, p = 0.02 vs. 58.93 ± 12.06%, p = 0.18). The absolute pre-test to 1-week post-test difference was significantly higher at 35.28 ± 7.65% among participants in the DD group compared to 25.0 ± 11.80% in the MD group, p = 0.048. Similarly, the absolute pre-test to 3-month post-test difference was significantly higher at 18.9 ± 6.7% among the participants in the DD group, compared to 6.8 ± 11.8% in the MD group, p = 0.021. Conclusions: Long-term nutrition knowledge is improved with DD compared with MD.

How much do gastroenterology fellows know about nutrition

Background Many people are afflicted with chronic diseases, in which nutrition plays a key role. The need for greater nutrition training among physicians, particularly gastroenterologists, is becoming increasingly evident. Objectives To determine the nutritional knowledge and perceived nutrition knowledge of gastroenterology fellows. Methods Thirty-two gastrointestinal (GI) fellows currently enrolled in a GI fellowship program completed a needs assessment evaluating perceived nutrition knowledge and interest in the areas of nutrition support, assessment, obesity, micro/macronutrients, and nutrition in GI diseases. Additionally, an examination evaluating nutrition knowledge specific to gastroenterology fellows was administered. Results Thirty-two GI fellows completed the needs assessment. Cronbach α of the needs assessment instrument was 0.72, indicating satisfactory internal consistency reliability. GI fellows perceived themselves to have the least knowledge in obesity and micro/macronutrients. They indicated a perceived greater knowledge base in nutrition assessment. The mean total test score was 50.04% (SD=7.84%). Fellows had the highest score in the subscale of nutrition assessment (80.64%; SD=19.05%), which was significantly higher than scores obtained in nutrition support (49.45%; SD=11.98%; P<0.05), micro/macronutrients (37.84%; SD=16.94%; P<0.05), obesity (40.11%; SD=20.00%; P<0.05), and nutrition in GI diseases (65.05%; SD=22.09%; P<0.05). A backward linear regression including hours of nutrition education received during GI fellowship, hours of nutrition education received during medical school, and year of GI fellowship accounted for 22.7% of the variance in test performance (multiple R=0.477). Conclusions Gastroenterology fellows think their knowledge of nutrition is suboptimal; objective evaluation of nutrition knowledge in this cohort confirmed this belief. A formal component of nutrition education could be developed in the context of GI fellowship education and continuing medical education as necessary.

The effect of differential rater function over time (DRIFT) on objective structured clinical examination ratings.

Context  Despite the impartiality implied in its title, the objective structured clinical examination (OSCE) is vulnerable to systematic biases, particularly those affecting raters’ performance. In this study our aim was to examine OSCE ratings for evidence of differential rater function over time (DRIFT), and to explore potential causes of DRIFT.

Refractory Crohn's disease of the vulva treated with infliximab : A case report

Crohns disease (CD) is a chronic relapsing and remitting inflammatory disorder of the gastrointestinal tract. The common presentation includes abdominal pain, abdominal cramping and diarrhea. Many patients may exhibit systemic symptoms of fever and weight loss. Approximately 20% to 40% of patients will experience extraintestinal manifestations that involve the eyes, skin and joints. Women may experience a variety of gynecological manifestations, including vulvovaginal involvement, which is often not recognized and also difficult to treat. A case of refractory vulvovaginal CD is presented and the literature of gynecological manifestations of CD and its treatment are reviewed.

Expert-Type Knowledge Structure in Medical Students is Associated With Increased Odds of Diagnostic Success

Abstract Background: The relation between knowledge structure and diagnostic performance is unclear. Similarly, variables affecting knowledge structure are poorly understood. Purpose: The 1st objective was to examine the relation between concepts in knowledge structure and diagnostic performance. The 2nd objective was to examine the relation between the use of diagnostic schemes by small-group preceptors and knowledge structure of medical students. Methods: This was a cross-sectional study of 1st-year medical students in 4 clinical presentations: hyponatremia, hyperkalemia, metabolic acidosis, and metabolic alkalosis. The 1st dependent variable was diagnostic success with the number of expert-type concepts in knowledge structure (determined by concept sorting), diagnostic scheme use by preceptors, and clinical presentation as independent variables. The 2nd dependent variable was the number of expert-type concepts in knowledge structure with diagnostic scheme use by preceptors and clinical presentation as independent variables. Data were analyzed using multiple logistic and linear regression. Results: Thirty 1st-year medical students participated. After adjusting for clinical presentation and scheme use by preceptors, the number of expert-type concepts in knowledge structure was associated with increased odds of diagnostic success (odds ratio 1.18 [1.03, 1.35], p = .016). After adjustment for clinical presentation, scheme use by preceptors was associated with increased number of expert-type concepts in knowledge structure (2.22 vs. 1.86, p = .01, d = 0.23). Conclusions: The number of expert-type concepts in knowledge structure is associated with increased odds of diagnostic success. Scheme use by small-group preceptors is associated with an increased number of expert-type concepts in knowledge structure.