Inconsistência metodológica no ensino da anamnese nas escolas de medicina

Säo analisados alguns aspectos característicos do processo de obtençäo da anamnese, do exame físico e formulaçäo de hipóteses diagnósticas: predominância de dados qualitativos, ausência de hipótese prévia a ser testada, envolvimento direto do observador (médico) com a fonte de dados (doente), formulaçäo e rejeiçäo de hipóteses e modificaçäo do doente durante o processo. Em vista disto, a investigaçäo diagnóstico guarda grande distância da metodología científica quantitativa, moldada no positivismo lógico, que domina toda a investigaçäo e educaçäo médica

How standardized are standardized patients?

The accuracy and reproducibility of the standardized patient's presentation of a clinical problem was evaluated in 15 cases used in the evaluation of fourth year medical students in two universities. There were differences in the quality of standardized patient presentation between institutions and among the cases presented.

Training and validating the use of geriatric simulated patients.

After presenting four patient roles during an audio-taped final examination of 68 second-year medical students' interview skills, seven geriatric simulated patients evaluated the interview skills of the students. Reviews of randomly-selected audiotapes revealed that the patients were highly consistent and accurate in their evaluations, indicating that geriatric simulated patients may be an untapped resource for medical training.

Cueing in multiple choice questions: a reliable, valid and economical solution.

Test questions dealing with diagnosis and management were administered to medical students in both multiple-choice format and an open-ended form which can be scored by computer. Open-ended questions are feasible to administer, equally reliable and may be more valid in certain domains than multiple-choice questions.

Writing vs coding diagnostic impressions in an examination: short-answer vs long-menu responses.

The rank order of clerks taking two parallel written examination on diagnostic skills were compared, one examination containing short-answer/free response questions, and the other long-menu/coded response questions. A positive rank-order correlation was found between the two question formats, thus suggesting that both formats measure the same abilities.

Evaluating diagnostic pattern recognition: the psychometric characteristics of a new item format.

The issues related to measuring pattern recognition are similar to measuring other clinical skills; how can testing time be used most efficiently to obtain reliable and valid scores? How should tests be constructed to obtain scores that validly reflect individual performance in making diagnoses? Generalizability analyses indicated that performance in one topic area does not predict performance in other areas very well. For example, students who were relatively expert in diagnosing patients with headaches tend not to be expert in diagnosing patients with chest pain, joint pain, etc. Therefore, to evaluate diagnostic pattern recognition skills in general, it is preferable to sample more presenting complaints with fewer items directed at each one, rather than to sample more items within a small number of presenting complaints. Approximately one hour of testing time would be required to generate a reasonably reliable score (ie, with a generalizability coefficient greater than 0.80). For diagnostic or remedial purposes, performance can be examined by content area to determine specific areas of weakness for individual students. The next phase of this study will be directed at determining whether there are benefits to using the current matching format with a relatively long list of response alternatives rather than a traditional multiple choice format with five choices. It is hypothesized that the shorter list differentially benefits the lower ability students and the more junior students. Efforts will also be directed to determining the applicability of the item format to other content areas such as diagnostic testing and therapy.

Effect of prior examples on rule-based diagnostic performance.

The studies test the role of examples in the learning of diagnostic rules in dermatology. The specific examples used are shown to have a substantial biasing effect on diagnostic accuracy.

Expertise in the clinical interview: a cognitive analysis.

The present study evaluates differences between subjects at three levels of expertise in acquiring and using information obtained from a patient during the clinical review. The results of the study suggest that the selective acquisition and the efficient utilization of information are hallmarks of expertise in the clinical review.

[Teaching medical diagnosis by computer simulation]. / Apprentissage du diagnostic médical par simulation sur ordinateur (AEDM).

A program of computer-assisted teaching, called AEDM, has been developed to simulate, with a conversational type terminal, the natural process of medical decision making. This system rests on two softwares, 'teaching' and 'inquiring', with 10 000 PASCAL instructions and the database of a computer-assisted diagnostic system (about 100 MO). The study describes the objectives and the characteristics of a system based on a simulation program; using natural procedures and non-specialized software is useful to develop computer-assisted teaching concerning different fields of pathology.

Clinical medicine for dental students.

A program in clinical medicine for dental students was introduced at the Tufts University School of Dental Medicine in 1974. Instruction in medical topics is delivered throughout the dental curriculum. Faculty and patient resources of the School of Dental Medicine, the School of Medicine, and the adjacent New England Medical Center Hospital are used. The ten-year evolution of this program is described in relation to the problems that had to be overcome. A survey of alumni indicated that the graduates who had taken the program felt better trained in physical evaluation techniques and reported higher frequencies of detecting medical problems in their patients than those who had not.