Can We Increase the Value and Decrease the Cost of Clinical Skills Assessment?

Although the authors do not agree with medical students' bid to end the United States Medical Licensing Examination Step 2 Clinical Skills or Comprehensive Osteopathic Medical Licensing Examination Level 2-Performance Evaluation tests, they concur with Ecker and colleagues that conducting further research to support the validity argument, providing greater feedback on performance, and exploring options to reduce costs are important for addressing students' concerns. Evidence to support the validity of clinical skills exam scores and associated inferences already exists. What is lacking, and would help further justify the use of these examinations, is more evidence to support the "extrapolation" argument-that is, is performance on these examinations related to actual patient care? Enhanced feedback on exam performance should also be considered. While performance data from licensing examinations should be used judiciously given the primary purpose of these tests, additional data would be helpful to learners and their institutions. Centralized testing remains the least costly design, but efficiencies of standardized patient training, case development, and scoring can be reviewed. Scoring modifications made in the past several years at substantial cost should be evaluated to determine whether they have achieved desired goals. Testing organizations can and should embrace these essential elements of transparency and accountability to address concerns about the value of clinical skills examinations.

Hip fracture: diagnosis, treatment, and secondary prevention.

Hip fractures cause significant morbidity and are associated with increased mortality. Women experience 80% of hip fractures, and the average age of persons who have a hip fracture is 80 years. Most hip fractures are associated with a fall, although other risk factors include decreased bone mineral density, reduced level of activity, and chronic medication use. Patients with hip fractures have pain in the groin and are unable to bear weight on the affected extremity. During the physical examination, displaced fractures present with external rotation and abduction, and the leg will appear shortened. Plain radiography with cross-table lateral view of the hip and anteroposterior view of the pelvis usually confirms the diagnosis. If an occult hip fracture is suspected and plain radiography is normal, magnetic resonance imaging should be ordered. Most fractures are treated surgically unless the patient has significant comorbidities or reduced life expectancy. The consulting orthopedic surgeon will choose the surgical procedure. Patients should receive prophylactic antibiotics, particularly against Staphylococcus aureus, before surgery. In addition, patients should receive thromboembolic prophylaxis, preferably with low-molecular-weight heparin. Rehabilitation is critical to long-term recovery. Unless contraindicated, bisphosphonate therapy should be used to reduce the risk of another hip fracture. Some patients may benefit from a fall-prevention assessment.

Inguinal hernias: diagnosis and management.

Inguinal hernias are one of the most common reasons a primary care patient may need referral for surgical intervention. The history and physical examination are usually sufficient to make the diagnosis. Symptomatic patients often have groin pain, which can sometimes be severe. Inguinal hernias may cause a burning, gurgling, or aching sensation in the groin, and a heavy or dragging sensation may worsen toward the end of the day and after prolonged activity. An abdominal bulge may disappear when the patient is in the prone position. Examination involves feeling for a bulge or impulse while the patient coughs or strains. Although imaging is rarely warranted, ultrasonography or magnetic resonance imaging can help diagnose a hernia in an athlete without a palpable impulse or bulge on physical examination. Ultrasonography may also be indicated with a recurrent hernia or suspected hydrocele, when the diagnosis is uncertain, or if there are surgical complications. Although most hernias are repaired, surgical intervention is not always necessary, such as with a small, minimally symptomatic hernia. If repair is necessary, the patient should be counseled about whether an open or laparoscopic technique is best. Surgical complications and hernia recurrences are uncommon. However, a patient with a recurrent hernia should be referred to the original surgeon, if possible.

Carpal tunnel syndrome.

Carpal tunnel syndrome is the most common entrapment neuropathy, affecting approximately 3 to 6 percent of adults in the general population. Although the cause is not usually determined, it can include trauma, repetitive maneuvers, certain diseases, and pregnancy. Symptoms are related to compression of the median nerve, which results in pain, numbness, and tingling. Physical examination findings, such as hypalgesia, square wrist sign, and a classic or probable pattern on hand symptom diagram, are useful in making the diagnosis. Nerve conduction studies and electromyography can resolve diagnostic uncertainty and can be used to quantify and stratify disease severity. Treatment options are based on disease severity. Six weeks to three months of conservative treatment can be considered in patients with mild disease. Lifestyle modifications, including decreasing repetitive activity and using ergonomic devices, have been traditionally advocated, but have inconsistent evidence to support their effectiveness. Cock-up and neutral wrist splints and oral corticosteroids are considered first-line therapies, with local corticosteroid injections used for refractory symptoms. Nonsteroidal anti-inflammatory drugs, diuretics, and pyridoxine (vitamin B6) have been shown to be no more effective than placebo. Most conservative treatments provide short-term symptom relief, with little evidence supporting long-term benefits. Patients with moderate to severe disease should be considered for surgical evaluation. Open and endoscopic surgical approaches have similar five-year outcomes.

Musculoskeletal disorders.

Musculoskeletal system complaints are one of the most common reasons that patients seek medical care. A significant number of these patients use complementary and alternative medicine. This article discusses the most common musculoskeletal problems for which patients present to a physician's office. These include osteoarthritis, rheumatoid arthritis, low back pain, neck pain, and myofascial pain syndrome.

Fostering rural physicians: the early success of the rural scholars track at Louisiana State University Health Sciences Center School of Medicine--New Orleans.

Louisiana is a predominantly rural state, with 86 percent of its parishes classified as areas of Primary Care Health Professional Shortages by the US Department of Health and Human Services. As a result, individuals living in these areas have limited access to primary medical care. In addition, data derived from the Association of American Medical Colleges Center for Workforce Studies clearly indicate that fewer and fewer medical-school graduates are choosing primary-care specialties as a career. This national trend has been noted here at the Louisiana State University Health Sciences Center (LSUHSC) School of Medicine - New Orleans. In order to address this decline, the School of Medicine created the Rural Scholars Track with the objective of producing primary-care physicians for Louisiana, in particular for rural areas. While the program is still in its early years, the results have been positive and hold hope for the future of health care in the state.

Common spider bites.

There are more than 30,000 species of spiders, most of which cannot inflict serious bites to humans because of their delicate mouthparts and impotent or prey-specific venoms. However, some spiders produce toxic venoms that can cause skin lesions, systemic illnesses, and neurotoxicity. One of the more common bites is inflicted by the widow spiders (Latrodectus species). A bite from a widow spider results in muscle spasms and rigidity starting at the bite site within 30 minutes to two hours. Another common bite is inflicted by the recluse spider (Loxosceles species). Most bites from these spiders occur early in the morning and are initially painless. These bites usually progress to ulcerating dermonecrosis at the bite site. Spider bites can be prevented by simple measures. Early species identification and specific management can prevent most serious sequelae of spider bites.

Ankle problems masquerading as sprains.

The most common ankle injury is a ligamentous sprain, usually involving the lateral side. This is usually treated very successfully with conservative management. Those patients who have continued complaints despite such management should be suspected of having something more than a simple sprain. The diagnostic entities discussed herein should always be part of the differential diagnosis of a sprained ankle, so that when one of these injuries is initially missed, the examining physician will be able to re-examine and eventually diagnose and treat these injuries properly. They should be managed appropriately as soon as possible for the best outcome. Needless delays should be avoided.

Groin pain in athletes.

Groin pain in athletes is not infrequently a cause of frustration and aggravation to both doctor and patient. Complaints in the groin region can prove difficult to diagnose, particularly when they are of a chronic nature. These injuries are seen more commonly in sports that require specific use (or overuse) of the proximal musculature of the thigh and lower abdominal muscles. Some of the more common sports would be soccer, skiing, hurdling, and hockey. The differential diagnosis can cover a rather broad area of possibilities. Most common groin injuries are soft-tissue injuries, such as muscular strains, tendinitis, or contusions. More difficult areas to pinpoint are such entities as osteitis pubis, nerve entrapment, the so-called "sports hernia," or avulsion fractures, to name but a few. The evaluation of such patients includes a familiarity with the sport and possible mechanism of injury (i.e., taking a careful history), meticulous physical examination of the groin, abdomen, hips, spine, and lower extremities. Diagnostic examinations may or may not prove helpful in formulating a final diagnosis. Some patients may be required to undergo procedures, such as laparoscopic evaluation of the region to obtain adequate information that allows a proper diagnosis and treatment plan. This article describes many of the possible causes of groin pain in athletes. The list is quite lengthy, and only the more common problems will be discussed in detail.