Exploring individual opinions of potential evaluators in a 360-degree assessment: four distinct viewpoints of a competent resident.

BACKGROUND: Despite the highly acclaimed psychometric features of a 360-degree assessment in the fields of economics, military, and education, there has been increased interest in developing 360-degree instruments to assess competencies in graduate medical education only in the past recent years. Most of the effort to date, however, has focused on developing instruments and testing their reliability and feasibility. Insufficient attention has gone into issues of construct validity and particularly understanding the underlying constructs on which the instruments are based as well as the phenomena that affect ratings. PURPOSE: In preparation for developing a 360-degree assessment instrument, we explored variations in evaluators' opinion type of a competent resident and offer observation about evaluator's professional background and opinions. METHOD: Evaluators from two residency programs ranked 36 opinion statements, using a relative-ranking model, based on their opinion of a competent resident. By-person factor analysis was used to structure opinion types. RESULTS: Factor analysis of 156 responses identified four factors interpreted as four different opinion types of a competent resident: (a) altruistic, compassionate healer (n = 42 evaluators), (b) scientifically grounded clinician (n = 30), (c) holistic, humanistic clinician (n = 62), and (d) patient-focused, health manager (n = 31). Although 72% of nurses/respiratory therapist evaluators expressed type C, 28% expressed other types just as often. Only 14% of evaluator physicians expressed type D, and the remainders were evenly split among the other types. CONCLUSIONS: Our evaluators in 360-degree system expressed four opinion types of a competent resident. The individual opinion and not professional background influences the characteristics an evaluator values in a competent resident. We propose that these values will have an impact on competency assessment and should be taken into account in a 360-degree assessment.

By-person factor analysis in clinical ethical decision making: Q methodology in end-of-life care decisions.

OBJECTIVE: To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues. DESIGN: Qualitative study using by-person factor analysis of subjective Q sort data matrix. SETTING: University medical center. PARTICIPANTS: Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center. INTERVENTIONS: Presented with four hypothetical cases involving urgent decision making near the end of life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases. MEASUREMENTS AND MAIN RESULTS: Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r2 < 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic impact on the physician, expediency in resolution of the situation, and the expense of medical treatment were not found to be influential determinants in this study. CONCLUSIONS: Q sorting and by-person factor analysis are useful qualitative methodological tools to study the complex structure of subjective attitudes that influence physicians in making medical decisions. This study revealed the subjective viewpoints used by our physician participants as they made ethically challenging treatment decisions. The three second-order factors identified here are grounded in current bioethical values as well as the personal traits of physicians. The participants' decision methods appear to resemble casuistry more than principle-based decision making. Generalizability of results will require further studies.

Role of echocardiography in detecting portopulmonary hypertension in liver transplant candidates.

Portopulmonary hypertension (PPHTN) is a recognized complication of end-stage liver disease that adversely affects the outcome of orthotopic liver transplantation (OLT). There are limited data on the role of Doppler echocardiography in assessing pulmonary artery systolic pressure (PASP) in this population. The purpose of our study was to examine the accuracy of Doppler echocardiography in evaluating pulmonary artery pressures in liver transplant candidates. Clinical and demographic data were gathered retrospectively for 78 liver transplant candidates (48 men and 30 women, mean age 51 +/- 9.6 yr) who had PASP determined both by right heart catheterization (RHC) and echocardiography. Paired sample t-test was used to compare mean PASP by echocardiography and RHC. Correlation of PASP between echocardiography and RHC was determined using Pearson's linear correlation. Positive and negative predictive values for echocardiography for PASP > 50 mmHg are reported as compared with RHC. The mean PASP by echocardiography (43.2 +/- 12.3 mm Hg) was significantly higher than mean PASP by RHC (33.7 +/- 15.5 mm Hg; P <.001). Regarding PASP, there was a significant but weak correlation between echocardiography and RHC (r = 0.46, P =.01). The positive and negative predictive values of echocardiography for identifying clinically significant pulmonary hypertension (PASP > 50 mm Hg) were 37.5% and 91.9%, respectively. Echocardiography is a useful tool in estimating PASP in liver transplant candidates. Patients with apparently elevated PASP by echocardiography should undergo invasive assessment by RHC before being excluded from liver transplant.