Experience of introducing an electronic health records station in an objective structured clinical examination to evaluate medical students' communication skills in Canada: a descriptive study.

PURPOSE: There is limited literature related to the assessment of electronic medical record (EMR)-related competencies. To address this gap, this study explored the feasibility of an EMR objective structured clinical examination (OSCE) station to evaluate medical students' communication skills by psychometric analyses and standardized patients' (SPs) perspectives on EMR use in an OSCE. METHODS: An OSCE station that incorporated the use of an EMR was developed and pilot-tested in March 2020. Students' communication skills were assessed by SPs and physician examiners. Students' scores were compared between the EMR station and 9 other stations. A psychometric analysis, including item total correlation, was done. SPs participated in a post-OSCE focus group to discuss their perception of EMRs' effect on communication. RESULTS: Ninety-nine 3rd-year medical students participated in a 10-station OSCE that included the use of the EMR station. The EMR station had an acceptable item total correlation (0.217). Students who leveraged graphical displays in counseling received higher OSCE station scores from the SPs (P=0.041). The thematic analysis of SPs' perceptions of students' EMR use from the focus group revealed the following domains of themes: technology, communication, case design, ownership of health information, and timing of EMR usage. CONCLUSION: This study demonstrated the feasibility of incorporating EMR in assessing learner communication skills in an OSCE. The EMR station had acceptable psychometric characteristics. Some medical students were able to efficiently use the EMRs as an aid in patient counseling. Teaching students how to be patient-centered even in the presence of technology may promote engagement.

OSCE Standard Setting: Three Borderline Group Methods.

High-stakes assessments must discriminate between examinees who are sufficiently competent to practice in the health professions and examinees who are not. In these settings, criterion-referenced standard-setting methods are strongly preferred over norm referenced methods. While there are many criterion-referenced options, few are feasible or cost effective for objective structured clinical examinations (OSCEs). The human and financial resources required to organize OSCEs alone are often significant, leaving little in an institution's budget for additional resource-intensive standard-setting methods. The modified borderline group method introduced by Dauphinee et al. for a large-scale, multi-site OSCE is a very feasible option but is not as defensible for smaller scale OSCEs. This study compared the modified borderline group method to two adaptations that address its limitations for smaller scale OSCEs while retaining its benefits, namely feasibility. We evaluated decision accuracy and consistency of calculated cut scores derived from (1) modified, (2) regression-based, and (3) 4-facet Rasch model borderline group methods. Data were from a 12-station OSCE that assessed 112 nurses for entry to practice in a Canadian context. The three cut scores (64-65%) all met acceptable standards of accuracy and consistency; however, the modified borderline group method was the most influenced by lower scores within the borderline group, leading to the lowest cut score. The two adaptations may be more defensible than modified BGM in the context of a smaller (n < 100-150) OSCE.

Written-Based Progress Testing: A Scoping Review.

PURPOSE: Progress testing is an increasingly popular form of assessment in which a comprehensive test is administered to learners repeatedly over time. To inform potential users, this scoping review aimed to document barriers, facilitators, and potential outcomes of the use of written progress tests in higher education. METHOD: The authors followed Arksey and O'Malley's scoping review methodology to identify and summarize the literature on progress testing. They searched 6 databases (Academic Search Complete, CINAHL, ERIC, Education Source, MEDLINE, and PsycINFO) on 2 occasions (May 22, 2018, and April 21, 2020) and included articles written in English or French and pertaining to written progress tests in higher education. Two authors screened articles for the inclusion criteria (90% agreement), then data extraction was performed by pairs of authors. Using a snowball approach, the authors also screened additional articles identified from the included reference lists. They completed a thematic analysis through an iterative process. RESULTS: A total of 104 articles were included. The majority of progress tests used a multiple-choice and/or true-or-false question format (95, 91.3%) and were administered 4 times a year (38, 36.5%). The most documented source of validity evidence was internal consistency (38, 36.5%). Four major themes were identified: (1) barriers and challenges to the implementation of progress testing (e.g., need for additional resources); (2) established collaboration as a facilitator of progress testing implementation; (3) factors that increase the acceptance of progress testing (e.g., formative use); and (4) outcomes and consequences of progress test use (e.g., progress testing contributes to an increase in knowledge). CONCLUSIONS: Progress testing appears to have a positive impact on learning, and there is significant validity evidence to support its use. Although progress testing is resource- and time-intensive, strategies such as collaboration with other institutions may facilitate its use.

Augmenting physician examiner scoring in objective structured clinical examinations: including the standardized patient perspective.

In Canada, high stakes objective structured clinical examinations (OSCEs) administered by the Medical Council of Canada have relied exclusively on physician examiners (PEs) for scoring. Prior research has looked at using SPs to replace PEs. This paper reports on two studies that implement and evaluate a standardized patient (SP) scoring tool to augment PE scoring. The unique aspect of this study is that it explores the benefits of combining SP and PE scores. SP focus groups developed rating scales for four dimensions they labelled: Listening, Communication, Empathy/Rapport, and Global Impression. In Study I, 43 SPs from one site of a national PE-scored OSCE rated 60 examinees with the initial SP rating scales. In Study II, 137 SPs used slightly revised rating scales with optional narrative comments to score 275 examinees at two sites. Examinees were blinded to SP scoring and SP ratings did not count. Separate PE and SP scoring was examined using descriptive statistics and correlations. Combinations of SP and PE scoring were assessed using pass-rates, reliability, and decision consistency and accuracy indices. In Study II, SP and PE comments were examined. SPs showed greater variability in their scoring, and rated examinees lower than PEs on common elements, resulting in slightly lower pass rates when combined. There was a moderate tendency for both SPs and PEs to make negative comments for the same examinee but for different reasons. We argue that SPs and PE assess performance from different perspectives, and that combining scores from both augments overall reliability of scores and pass/fail decisions. There is potential to provide examinees with feedback comments from each group.

Canadians studying medicine abroad and their journey to secure postgraduate training in Canada or the United States.

BACKGROUND: From national and international workforce perspectives, Canadians studying medicine abroad (CSAs) are a growing provider group. Some were born in Canada whereas others immigrated as children. They study medicine in various countries, often attempting both American and Canadian medical licensure pathways. METHODS: Using data from the Educational Commission for Foreign Medical Graduates (ECFMG) and the Medical Council of Canada (MCC), we looked at CSAs who attempted to secure residency positions in both Canada and the United States. We detailed the CSAs' countries of birth and medical education. We tracked these individuals through their postgraduate education programs to enumerate their success rate and categorize the geographic locations of their training. RESULTS: The majority of CSAs study medicine in one of 10 countries. The remainder are disbursed across 88 other countries. Most CSAs were born in Canada (62%). Approximately 1/3 of CSA from the 2004-2016 cohort had no record of entering a residency program in Canada or the United States (U.S.). Recently graduated CSAs were most likely to secure residency training in Ontario and New York. CONCLUSION: Many CSAs attempt to secure residency training in both Canada and the U.S. Quantifying success rates may be helpful for Canadians thinking about studying medicine abroad. Understanding the educational pathways of CSAs will be useful for physician labour workforce planning.

CONTEXTE: Selon une perspective nationale et internationale des effectifs, les Canadiens qui étudient la médecine à l'étranger (CEE) représentent un groupe en croissance. Certains sont nés au Canada, alors que d'autres ont immigré durant leur enfance. Ils étudient la médecine dans divers pays, essayant souvent parallèlement d'obtenir un permis américain et canadien pour exercer la médecine. MÉTHODES: À l'aide de données de l'Educational Commission for Foreign Medical Graduates (ECFMG) et du Conseil médical du Canada (CMC), nous avons examiné les CEE qui avaient tenté d'obtenir des postes de résidence à la fois au Canada et aux États-Unis. Nous avons extrait des données quant au pays de naissance et à la formation médicale de ces CEE. Nous avons suivi ces personnes dans leurs processus de demande d'admission à des programmes de formation postdoctorale pour rapporter leur taux de succès et catégoriser les emplacements géographiques de leur formation. RÉSULTATS: Nous avons identifié 10 pays d'où provenaient la plupart de ces CEE. Les autres CEE provenaient de 88 autres pays. La plupart de ces CEE sont nées au Canada (62 %). Environ 1/3 des CEE de la cohorte de 2004 à 2016 ne possède pas de dossier d'inscription à un programme de résidence au Canada ou aux États-Unis. Les CEE récemment diplômés étaient les plus susceptibles de suivre une formation en résidence en Ontario et dans l'État de New York. CONCLUSION: De nombreux CEE ont tenté d'obtenir un poste de résidence au Canada et aux États-Unis. Quantifier les taux de succès pourrait se révéler utile pour les Canadiens qui pensent à étudier la médecine à l'étranger. Comprendre les parcours éducatifs des CEE sera utile à la planification des effectifs médicaux.

A method for identifying extreme OSCE examiners.

BACKGROUND: Performance assessments rely on human judgment, and are vulnerable to rater effects (e.g. leniency or harshness). Making valid inferences from performance ratings for high-stakes decisions requires the management of rater effects. A simple method for detecting extreme raters that does not require sophisticated statistical knowledge or software has been developed as part of the quality assurance process for objective structured clinical examinations (OSCEs). We believe it is applicable to a range of examinations that rely on human raters. METHODS: The method has three steps. First, extreme raters are identified by comparing individual rater means with the mean of all raters. A rater is deemed extreme if their mean was three standard deviations below (hawks) or above (doves) the overall mean. This criterion is adjustable. Second, the distribution of an extreme rater's scores was compared with the overall distribution for the station. This step mitigates a station effect. Third, the cohort of candidates seen by the rater is examined to ensure that any cohort effect is ruled out. RESULTS AND IMPLICATIONS: Of 3000+ raters, fewer than 0.3% have been identified as being extreme using the proposed criteria. Rater performance is being monitored on a regular basis, and the impact of these raters on candidate results will be considered before results are finalised. Extreme raters are contacted by the organisation to review their rating style. If this intervention fails to modify the rater's scoring pattern, the rater is no longer invited back. As more data are collected the organisation will assess them to inform the development of approaches to improve extreme rater performance.

Influence of physicians' management and communication ability on patients' persistence with antihypertensive medication.

BACKGROUND: Less than 75% of people prescribed antihypertensive medication are still using treatment after 6 months. Physicians determine treatment, educate patients, manage side effects, and influence patient knowledge and motivation. Although physician communication ability likely influences persistence, little is known about the importance of medical management skills, even though these abilities can be enhanced through educational and practice interventions. The purpose of this study was to determine whether a physician's medical management and communication ability influence persistence with antihypertensive treatment. METHODS: This was a population-based study of 13,205 hypertensive patients who started antihypertensive medication prescribed by a cohort of 645 physicians entering practice in Quebec, Canada, between 1993 and 2007. Medical Council of Canada licensing examination scores were used to assess medical management and communication ability. Population-based prescription and medical services databases were used to assess starting therapy, treatment changes, comorbidity, and persistence with antihypertensive treatment in the first 6 months. RESULTS: Within 6 months after starting treatment, 2926 patients (22.2%) had discontinued all antihypertensive medication. The risk of nonpersistence was reduced for patients who were treated by physicians with better medical management (odds ratio per 2-SD increase in score, 0.74; 95% confidence interval, 0.63-0.87) and communication (0.88; 0.78-1.00) ability and with early therapy changes (odds ratio, 0.45; 95% confidence interval, 0.37-0.54), more follow-up visits, and nondiuretics as the initial choice of therapy. Medical management ability was responsible for preventing 15.8% (95% confidence interval, 7.5%-23.3%) of nonpersistence. CONCLUSION: Better clinical decision-making and data collection skills and early modifications in therapy improve persistence with antihypertensive therapy.

Doctor scores on national qualifying examinations predict quality of care in future practice.

OBJECTIVES: This study aimed to determine if national licensing examinations that measure medical knowledge (QE1) and clinical skills (QE2) predict the quality of care delivered by doctors in future practice. METHODS: Cohorts of doctors who took the Medical Council of Canada Qualifying Examinations Part I (QE1) and Part II (QE2) between 1993 and 1996 and subsequently entered practice in Ontario, Canada (n = 2420) were followed for their first 7-10 years in practice. The 208 of these doctors who were randomly selected for peer assessment of quality of care were studied. Main outcome measures included quality of care (acceptable/unacceptable) as assessed by doctor peer-examiners using a structured chart review and interview. Multivariate logistic regression was used to determine if qualifying examination scores predicted the outcome of the peer assessments while controlling for age, sex, training and specialty, and if the addition of the QE2 scores provided additional prediction of quality of care. RESULTS: Fifteen (7.2%) of the 208 doctors assessed were considered to provide unacceptable quality of care. Doctors in the bottom quartile of QE1 scores had a greater than three-fold increase in the risk of an unacceptable quality-of-care assessment outcome (odds ratio [OR] 3.41, 95% confidence interval [CI] 1.14-10.22). Doctors in the bottom quartile of QE2 scores were also at higher risk of being assessed as providing unacceptable quality of care (OR 4.24, 95% CI 1.32-13.61). However, QE2 results provided no significant improvement in predicting peer assessment results over QE1 results (likelihood ratio test: chi(2) = 3.21, P-value((1 d.f.)) = 0.07). CONCLUSIONS: Doctor scores on qualifying examinations are significant predictors of quality-of-care problems based on regulatory, practice-based peer assessment.

Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities.

CONTEXT: Poor patient-physician communication increases the risk of patient complaints and malpractice claims. To address this problem, licensure assessment has been reformed in Canada and the United States, including a national standardized assessment of patient-physician communication and clinical history taking and examination skills. OBJECTIVE: To assess whether patient-physician communication examination scores in the clinical skills examination predicted future complaints in medical practice. DESIGN, SETTING, AND PARTICIPANTS: Cohort study of all 3424 physicians taking the Medical Council of Canada clinical skills examination between 1993 and 1996 who were licensed to practice in Ontario and/or Quebec. Participants were followed up until 2005, including the first 2 to 12 years of practice. MAIN OUTCOME MEASURE: Patient complaints against study physicians that were filed with medical regulatory authorities in Ontario or Quebec and retained after investigation. Multivariate Poisson regression was used to estimate the relationship between complaint rate and scores on the clinical skills examination and traditional written examination. Scores are based on a standardized mean (SD) of 500 (100). RESULTS: Overall, 1116 complaints were filed for 3424 physicians, and 696 complaints were retained after investigation. Of the physicians, 17.1% had at least 1 retained complaint, of which 81.9% were for communication or quality-of-care problems. Patient-physician communication scores for study physicians ranged from 31 to 723 (mean [SD], 510.9 [91.1]). A 2-SD decrease in communication score was associated with 1.17 more retained complaints per 100 physicians per year (relative risk [RR], 1.38; 95% confidence interval [CI], 1.18-1.61) and 1.20 more communication complaints per 100 practice-years (RR, 1.43; 95% CI, 1.15-1.77). After adjusting for the predictive ability of the clinical decision-making score in the traditional written examination, the patient-physician communication score in the clinical skills examination remained significantly predictive of retained complaints (likelihood ratio test, P < .001), with scores in the bottom quartile explaining an additional 9.2% (95% CI, 4.7%-13.1%) of complaints. CONCLUSION: Scores achieved in patient-physician communication and clinical decision making on a national licensing examination predicted complaints to medical regulatory authorities.