An interactive patient simulation for the study of medical decision-making.

An interactive patient simulation for the study of medical decision-making was developed which is basically a flexible question and answer simulation between a doctor and a simulator conducting the simulation. To insure a thorough insight into the management of cases over time, provisions were made for doctors to interact with the simulated patients as many as five times. The simulation was tested on 16 family doctors and 16 specialist physicians to evaluate its realism and construct validity. The realism scores were highly favourable for both groups. With regard to construct validity, the hypothesis that the two specialty groups would manifest themselves in decision-making as distinct and homogeneous groups was tested. This hypothesis was confirmed in the case of specialist physicians, but not in the case of family doctors.

Diagnosis of transient ischemic attacks: improvement of interobserver agreement by a check-list in ordinary language.

To try and improve the interobserver agreement for the diagnosis of TIA, we used a checklist in which the symptoms were recorded in plain language, instead of in abstract diagnostic terms such as amaurosis fugax. Criteria for a diagnosis of TIA were similarly phrased and recommended to all observers. Eight senior neurologists and ten neurology residents interviewed 72 patients in random pairs. In 64 cases the observers agreed on the diagnosis (kappa value = 0.77). After a short discussion between the two observers the agreement increased to a maximum (kappa = 1.0). However, in 29 of the 144 interviews the diagnosis would have been different, had the recommended criteria been fully applied. In 28 of these the observer had diagnosed TIA on insufficient evidence. Six "misinterpretations" led to disagreement for the diagnosis and only these were corrected by the observers during their discussion. The present design has led to a maximal agreement for the diagnosis of TIA between two observers, but the agreement between such a pair and the common diagnostic criteria was not yet ideal. The precision of the diagnosis could be improved if details of the required symptoms are discussed in general as well as for each patient.

Skills development by medical students and the influence of prior experience: a study using evaluation by students and self-assessment.

Research was carried out into the effectiveness of an innovative, problem-based introductory course which was designed to help medical students, within a traditional curriculum, to bridge the gap between theoretical study during the first 4 years and inservice training during the next 2 years. Comparison of exit and entry self-assessment ratings of students showed a marked rise for history-taking and physical examination and a smaller rise for diagnosis and patient management. Cross-study of these self-assessment ratings and the background variable of past medical training showed that prior active experience within the health care system appeared to have a favourable influence on both history-taking and more intellectual skills, notably diagnosis and patient management. History-taking, however, could be taught as effectively during the introductory course. This was not so for the more intellectual skills. The results of this research plead for early active experience within the health care system during the medical curriculum, in order to give the students more insight into the clinical relevance of their theoretical studies. Evaluation by the students of the teaching formats used to reach the learning objectives was favourable, especially of those formats related to concrete practical skills such as live simulated (programmed) patients. It was rather unfavourable to self-study facilities which provide more theoretical knowledge.

Medical interviewing: initial student problems.

Although every lecturer in a department of medical education would endorse the importance of sound medical interviewing the position of courses on this subject is generally unstressed. In the past few years a course has been developed in the Department of Internal Medicine at the University hospital of Utrecht in which special attention is paid to the sort of problems students experience in the initial phase of medical interviewing. Use is made of simulated patients. At the same time attention is given to both the medical and communicative aspects. This approach is specially appreciated by the students. Self assessment shows that they report a considerably enhanced proficiency. Observations and questionnaires show that the students have problems mostly on the emotional level, both in coping with their own emotions and in discussing personal and emotional topics with a patient.