Validity, reliability and feasibility of a new observation rating tool and a post encounter rating tool for the assessment of clinical reasoning skills of medical students during their internal medicine clerkship: a pilot study.

BACKGROUND: Systematic assessment of clinical reasoning skills of medical students in clinical practice is very difficult. This is partly caused by the lack of understanding of the fundamental mechanisms underlying the process of clinical reasoning. METHODS: We previously developed an observation tool to assess the clinical reasoning skills of medical students during clinical practice. This observation tool consists of an 11-item observation rating form (ORT). In the present study we verified the validity, reliability and feasibility of this tool and of an already existing post-encounter rating tool (PERT) in clinical practice among medical students during the internal medicine clerkship. RESULTS: Six raters each assessed the same 15 student-patient encounters. The internal consistency (Cronbach's alfa) for the (ORT) was 0.87 (0.71-0.84) and the 5-item (PERT) was 0.81 (0.71-0.87). The intraclass-correlation coefficient for single measurements was poor for both the ORT; 0.32 (p < 0.001) as well as the PERT; 0.36 (p < 0.001). The Generalizability study (G-study) and decision study (D-study) showed that 6 raters are required to achieve a G-coefficient of > 0.7 for the ORT and 7 raters for the PERT. The largest sources of variance are the interaction between raters and students. There was a consistent correlation between the ORT and PERT of 0.53 (p = 0.04). CONCLUSIONS: The ORT and PERT are both feasible, valid and reliable instruments to assess students' clinical reasoning skills in clinical practice.

The impact of the implementation of physician assistants in inpatient care: A multicenter matched-controlled study.

BACKGROUND: Medical care for admitted patients in hospitals is increasingly reallocated to physician assistants (PAs). There is limited evidence about the consequences for the quality and safety of care. This study aimed to determine the effects of substitution of inpatient care from medical doctors (MDs) to PAs on patients' length of stay (LOS), quality and safety of care, and patient experiences with the provided care. METHODS: In a multicenter matched-controlled study, the traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which besides MDs also PAs are employed (PA/MD model). Thirty-four wards were recruited across the Netherlands. Patients were followed from admission till one month after discharge. Primary outcome measure was patients' LOS. Secondary outcomes concerned eleven indicators for quality and safety of inpatient care and patients' experiences with the provided care. RESULTS: Data on 2,307 patients from 34 hospital wards was available. The involvement of PAs was not significantly associated with LOS (ß 1.20, 95%CI 0.99-1.40, p = .062). None of the indicators for quality and safety of care were different between study arms. However, the involvement of PAs was associated with better experiences of patients (ß 0.49, 95% CI 0.22-0.76, p = .001). CONCLUSIONS: This study did not find differences regarding LOS and quality of care between wards on which PAs, in collaboration with MDs, provided medical care for the admitted patients, and wards on which only MDs provided medical care. Employing PAs seems to be safe and seems to lead to better patient experiences. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01835444.

Observable phenomena that reveal medical students' clinical reasoning ability during expert assessment of their history taking: a qualitative study.

BACKGROUND: During their clerkships, medical students are meant to expand their clinical reasoning skills during their patient encounters. Observation of these encounters could reveal important information on the students' clinical reasoning abilities, especially during history taking. METHODS: A grounded theory approach was used to analyze what expert physicians apply as indicators in their assessment of medical students' diagnostic reasoning abilities during history taking. Twelve randomly selected clinical encounter recordings of students at the end of the internal medicine clerkships were observed by six expert assessors, who were prompted to formulate their assessment criteria in a think-aloud procedure. These formulations were then analyzed to identify the common denominators and leading principles. RESULTS: The main indicators of clinical reasoning ability were abstracted from students' observable acts during history taking in the encounter. These were: taking control, recognizing and responding to relevant information, specifying symptoms, asking specific questions that point to pathophysiological thinking, placing questions in a logical order, checking agreement with patients, summarizing and body language. In addition, patients' acts and the course, result and efficiency of the conversation were identified as indicators of clinical reasoning, whereas context, using self as a reference, and emotion/feelings were identified by the clinicians as variables in their assessment of clinical reasoning. CONCLUSIONS: In observing and assessing clinical reasoning during history taking by medical students, general and specific phenomena to be used as indicators for this process could be identified. These phenomena can be traced back to theories on the development and the process of clinical reasoning.

The Use of the Ambulatory Arterial Stiffness Index in Patients Suspected of Secondary Hypertension.

The ambulatory arterial stiffness index (AASI) is a marker of arterial stiffness and is derived from ambulatory 24-h blood pressure registration. We studied whether the AASI could be used as a predictive factor for the presence of renal artery stenosis (RAS) in patients with a suspicion of secondary hypertension and as such as a diagnostic tool for RAS. We included 169 patients with difficult-to-treat hypertension. They all underwent 24-h ambulatory blood pressure monitoring registration, imaging of the renal arteries, and cardiovascular risk measurement, including smoking, history, biometrics, blood pressure, renal function, lipids, and glucose metabolism. Performing univariate and multivariate analyses, we investigated if AASI and the other cardiovascular risk factors were related to the presence of RAS. Of the 169 patients (49% women), 31% had RAS. The mean AASI was 0.44 (0.16). The presence of RAS showed no significant correlation with AASI (r = 0.14, P = 0.06). Age (r = 0.19, P = 0.01), hypercholesterolemia (r = 0.26, P = 0.001), history of CVD (r = 0.22, P = 0.004), and creatinine clearance (r = -0.34, P < 0.001) all demonstrated a correlation with RAS. Although AASI is higher in patients with RAS, AASI does not independently predict the presence of RAS in hypertensive subjects.

Analysis of the level of general clinical skills of physician assistant students using an objective structured clinical examination.

RATIONALE, AIMS AND OBJECTIVES: The physician assistant (PA) is trained to perform clinical tasks traditionally performed by medical doctors (MDs). Previous research showed no difference in the level of clinical skills of PAs compared with MDs in a specific niche, that is the specialty in which they are employed. However, MDs as well as PAs working within a specialty have to be able to recognize medical problems in the full scope of medicine. The objective is to examine PA students' level of general clinical skills across the breadth of clinical cases. METHOD: A cross-sectional study was conducted. PA students and recently graduated MDs in the Netherlands were observed on their clinical skills by means of an objective structured clinical examination comprising five stations with common medical cases. The level of mastering history taking, physical examination, communication and clinical reasoning of PA students and MDs were described in means and standard deviation. Cohen's d was used to present effect sizes. RESULTS: PA students and MDs score about equal on history taking (PA 5.8 ± 0.8 vs. MD 5.7 ± 0.7), physical examination (PA 4.8 ± 1.3 vs. MD 5.4 ± 0.8) and communication (PA: 8.2 ± 0.8 vs. MD: 8.6 ± 0.5) in the full scope of medicine. In the quality of the report, including the patient management plan, PA students scored a mean of 6.0 ± 0.6 and MDs 6.8 ± 0.6. CONCLUSIONS: In this setting in the Netherlands, PA students and MDs score about equal in the appraisal of common cases in medical practice. The slightly lower scores of PA students' clinical reasoning in the full scope of clinical care may have raise attention to medical teams working with PAs and PA training programmes.

Student performance of the general physical examination in internal medicine: an observational study.

BACKGROUND: Many practicing physicians lack skills in physical examination. It is not known whether physical examination skills already show deficiencies after an early phase of clinical training. At the end of the internal medicine clerkship students are expected to be able to perform a general physical examination in every new patient encounter. In a previous study, the basic physical examination items that should standardly be performed were set by consensus. The aim of the current observational study was to assess whether medical students were able to correctly perform a general physical examination regarding completeness as well as technique at the end of the clerkship internal medicine. METHODS: One hundred students who had just finished their clerkship internal medicine were asked to perform a general physical examination on a standardized patient as they had learned during the clerkship. They were recorded on camera. Frequency of performance of each component of the physical examination was counted. Adequacy of performance was determined as either correct or incorrect or not assessable using a checklist of short descriptions of each physical examination component. A reliability analysis was performed by calculation of the intra class correlation coefficient for total scores of five physical examinations rated by three trained physicians and for their agreement on performance of all items. RESULTS: Approximately 40% of the agreed standard physical examination items were not performed by the students. Students put the most emphasis on examination of general parameters, heart, lungs and abdomen. Many components of the physical examination were not performed as was taught during precourses. Intra-class correlation was high for total scores of the physical examinations 0.91 (p <0.001) and for agreement on performance of the five physical examinations (0.79-0.92 p <0.001). CONCLUSIONS: In conclusion, performance of the general physical examination was already below expectation at the end of the internal medicine clerkship. Possible causes and suggestions for improvement are discussed.

[Renal artery stenosis: do not toss the stent aside]. / Nierarteriestenose: gooi de stent niet zomaar opzij.

Primary stent placement for atherosclerotic renal artery stenosis (ARAS) has become a subject of considerable debate. It even seems that the indication has been cast aside altogether, maybe as a result of prospective trials seeking to define the role of renal revascularisation, which failed to establish a compelling benefit for endovascular stenting when added to effective medical regimens. Various explanations for these disappointing results have been offered. However, it could be that the currently accepted belief, i.e. that only stenoses greater than 50-70% of the luminal surface result in ischaemic changes leading to hypertension and renal insufficiency, needs rethinking. There is ample experimental evidence that ischaemia per se does not fully explain the clinical sequelae accompanying ARAS. Treatment of advanced stenosis and renal derangement might be unsuccessful because the changes resulting from these conditions are already irreversible. Perhaps treatment should be initiated earlier in the disease process when stenosis and renal impairment are less advanced.

[Task shifting and quality of care in practice; physician assistants compared with anaesthesiology residents in the preoperative anaesthesiology outpatient clinic]. / Taakverschuiving en kwaliteit van zorg in de praktijk: physician assistant versus aios op de preoperatieve poli anesthesiologie.

OBJECTIVE: To compare the clinical competencies of second-year anaesthesiology residents and physician assistants (PA) in the preoperative anaesthesiology outpatient clinic. DESIGN: Comparative qualitative observational study. METHOD: The two study groups were compared using 5 test stations representing 5 different cases of varying degrees of complexity with standardized patients. For each case, the patients and two anaesthesiologists assessed the results of the PAs and the residents using a quantitative scoring system for 4 clinical skills relevant to the preoperative anaesthesiology outpatient clinic. These skills were history-taking, physical examination, communication, and reporting. At each station, a score was calculated for each skill. The groups' scores were subsequently compared. RESULTS: 9 PAs and 11 residents carried out the station tests. There were no significant differences between the two groups of participants. CONCLUSION: In this study in a preoperative anaesthesiology outpatient clinic no difference in clinical competencies was found between PAs and second-year anaesthesiology residents.

A core physical examination in internal medicine: what should students do and how about their supervisors?

BACKGROUND: Performance of a focused physical examination will induce a high cognitive load for medical students in the early phase of the clinical clerkships. AIM: To come to a workable and clinically applicable standard physical examination for medical students to be used in every new patient in the daily clinical practice of internal medicine. METHOD: A questionnaire held among physicians that supervise students during the clerkship of internal medicine in one Dutch training region. RESULTS: Of the complete list of physical examination 55 items were considered to be an integral part of the standard general physical examination for medical students. Most emphasized were elements of the physical examination aimed at general parameters, thorax and abdomen, vascular status, lymph nodes, spinal column, skin and some parts of the neurological examination. The standard physical examinations performed by supervisors themselves contain fewer items than they expected from the students. The expectations a supervisor has towards the student correlates with the frequency with which they apply the various components in their own physical examination. CONCLUSION: This study provides us with a 'core' physical examination for medical students that can be applied in the early phase of the clinical clerkships.

The efficacy of renal angioplasty in patients with renal artery stenosis and flash oedema or congestive heart failure: a systematic review.

AIMS: Recent randomized controlled trials have reported that angioplasty does not have a beneficial effect compared with pharmacological treatment on blood pressure and renal function in patients with atherosclerotic renal artery stenosis (RAS). We aimed to explore systematically the evidence that angioplasty is effective in subgroups of patients with RAS and either flash pulmonary oedema or congestive heart failure (CHF) and renal insufficiency. METHODS AND RESULTS: We searched online databases (PubMed and ClinicalTrials.gov) and references of included articles. We included 25 articles describing 79 patients with RAS and flash oedema and seven articles describing 94 patients with RAS, CHF, and renal insufficiency. According to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, the quality of the evidence was, at best, low. Seventy-six per cent of patients with flash oedema did not have any recurrence after angioplasty. Recurrence of symptoms was associated with either restenosis of the renal artery or cardiac arrhythmias in all patients. In the patients with CHF and renal insufficiency, the severity of heart failure symptoms, expressed as New York Heart Association (NYHA) functional class, improved after angioplasty in all included articles. CONCLUSION: The evidence included in this systematic review justifies a weak recommendation in favour of angioplasty in patients with atherosclerotic RAS and either flash pulmonary oedema or CHF and renal insufficiency.

['You may go ahead and get undressed now']. / 'Kleedt u zich maar even uit'.

For an experienced physician, it is common practice that the patient undresses for a physical examination. Medical students and young doctors can be more restrained. Unfamiliarity, feelings of shame and fear of being accused of sexual intimidation can prevent them from having the patient undress. This can lead to an incomplete performance of the physical examination by young doctors, and to missed diagnoses. This article's aim is to offer educators guidance to help young doctors in dealing with this subject.

Checking the checklist: a content analysis of expert- and evidence-based case-specific checklist items.

OBJECTIVES: Research on objective structured clinical examinations (OSCEs) is extensive. However, relatively little has been written on the development of case-specific checklists on history taking and physical examination. Background information on the development of these checklists is a key element of the assessment of their content validity. Usually, expert panels are involved in the development of checklists. The objective of this study is to compare expert-based items on OSCE checklists with evidence-based items identified in the literature. METHODS: Evidence-based items covering both history taking and physical examination for specific clinical problems and diseases were identified in the literature. Items on nine expert-based checklists for OSCE examination stations were evaluated by comparing them with items identified in the literature. The data were grouped into three categories: (i) expert-based items; (ii) evidence-based items, and (iii) evidence-based items with a specific measure of their relevance. RESULTS: Out of 227 expert-based items, 58 (26%) were not found in the literature. Of 388 evidence-based items found in the literature, 219 (56%) were not included in the expert-based checklists. Of these 219 items, 82 (37%) had a specific measure of importance, such as an odds ratio for a diagnosis, making that diagnosis more or less probable. CONCLUSIONS: Expert-based, case-specific checklist items developed for OSCE stations do not coincide with evidence-based items identified in the literature. Further research is needed to ascertain what this inconsistency means for test validity.

The clinical skills assessment for international medical graduates in The Netherlands.

AIM: A need was felt to improve the quality of admission and licensing procedures for international medical graduates in The Netherlands. METHOD: A clinical skills assessment was designed as part of a new procedure to realize a high-stakes, fair, transparent, and a time-limited path of admission for international medical graduates to the Dutch health care system. Additionally, it should provide a well-founded advice about length and content of additional medical training, should this be indicated by the outcome of the assessment. RESULTS: The clinical skills assessment procedure was developed as a Dutch variant of the "Step 2 Clinical Skills examination" of the Educational Commission for Foreign Medical Graduates (ECFMG) in collaboration with the United States National Board of Medical Examiners, which has a well-documented validity and reliability. The experience with the new procedure is yet limited, but enough to warrant a report. DISCUSSION: Worldwide, a number of countries have developed such high-stake assessment procedures, but they show little uniformity and transparency. By describing the design and development of our procedure, we do not pretend to set a standard, but we hope to contribute to more fair, accurate and uniform approaches for doctors moving from one country to another.

Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial.

BACKGROUND: Little is known about the efficacy and safety of renal artery stenting in patients with atherosclerotic renal artery stenosis (ARAS) and impaired renal function. OBJECTIVE: To determine the efficacy and safety of stent placement in patients with ARAS and impaired renal function. DESIGN: Randomized clinical trial. Randomization was centralized and computer generated, and allocation was assigned by e-mail. Patients, providers, and persons who assessed outcomes were not blinded to treatment assignment. SETTING: 10 European medical centers. PARTICIPANTS: 140 patients with creatinine clearance less than 80 mL/min per 1.73 m(2) and ARAS of 50% or greater. INTERVENTION: Stent placement and medical treatment (64 patients) or medical treatment only (76 patients). Medical treatment consisted of antihypertensive treatment, a statin, and aspirin. MEASUREMENTS: The primary end point was a 20% or greater decrease in creatinine clearance. Secondary end points included safety and cardiovascular morbidity and mortality. RESULTS: Forty-six of 64 patients assigned to stent placement had the procedure. Ten of the 64 patients (16%) in the stent placement group and 16 patients (22%) in the medication group reached the primary end point (hazard ratio, 0.73 [95% CI, 0.33 to 1.61]). Serious complications occurred in the stent group, including 2 procedure-related deaths (3%), 1 late death secondary to an infected hematoma, and 1 patient who required dialysis secondary to cholesterol embolism. The groups did not differ for other secondary end points. LIMITATION: Many patients were falsely identified as having renal artery stenosis greater than 50% by noninvasive imaging and did not ultimately require stenting. CONCLUSION: Stent placement with medical treatment had no clear effect on progression of impaired renal function but led to a small number of significant procedure-related complications. The study findings favor a conservative approach to patients with ARAS, focused on cardiovascular risk factor management and avoiding stenting.

Mechanisms of adenosine-induced renal vasodilatation in hypertensive patients.

BACKGROUND: Adenosine is an endogenous nucleoside with potent vasodilatory capacities, released under ischaemic conditions in particular. Its mechanisms of action, however, remain elusive. OBJECTIVE: To evaluate the role of adenosine, using a non-selective purinergic receptor antagonist, and the possible involvement of nitric oxide in this mechanism. In addition, the production of renin and catecholamines was studied during infusion of adenosine, caffeine, or both. METHODS: Thirty-three hypertensive patients who underwent diagnostic renal angiography received intrarenal infusions of adenosine either alone or in combination with caffeine or the nitric oxide synthase inhibitor, N-monomethyl-L-arginine (L-NMMA). The effects on renal blood flow (RBF) were assessed by the xenon-133 washout technique and both arterial and renal venous blood samples were taken for measurement of renin and catecholamine concentrations. Intra-arterial blood pressure and heart rate were monitored continuously. RESULTS: Adenosine induced a dose-dependent vasodilatation. Caffeine alone did not change RBF, but shifted the dose-response curve of adenosine to the right during concomitant infusion of caffeine. RBF during combined infusion of L-NMMA and adenosine was not different from that during adenosine alone, but the decrease in renal vascular resistance was less pronounced during this combination. Renin secretion did not change during the infusion of either adenosine alone or adenosine in combination with caffeine. Catecholamine concentrations also did not change during any of the experiments. CONCLUSIONS: Adenosine induces vasodilatation in the human hypertensive kidney and this effect is mediated by the adenosine receptor. Nitric oxide plays, at most, a minor part in the adenosine-induced vasodilatation. Furthermore, renin secretion is not affected by adenosine and caffeine.

Validation of a prediction rule for renal artery stenosis.

OBJECTIVES: We previously developed a prediction rule to estimate the probability of renal artery stenosis. This rule should be validated before it can be used reliably to select hypertensive patients for renal angiography. We determined the validity of the prediction rule in recent patients and in other settings. DESIGN: We studied three aspects of validity (agreement between predicted and observed probability of stenosis, discriminative ability, and clinical usefulness) in 180 consecutive patients with drug-resistant hypertension and normal or mildly impaired renal function, who visited six hypertension clinics of academic and community hospitals in the Netherlands. Thirty-five patients (19%) had a significant stenosis. RESULTS: The clinical characteristics in the rule (age, sex, vascular disease, recent onset of hypertension, smoking, body mass index, abdominal bruit, serum creatinine concentration, and hypercholesterolemia) had similar predictive value in the validation sample and development sample. The predicted probabilities of stenosis agreed well with the observed frequencies (Hosmer-Lemeshow goodness-of-fit test, P = 0.87). The prediction rule discriminated reasonably between patients with and without stenosis in the validation sample with an area under the receiver operating characteristic curve of 0.71. If only patients with predicted probabilities of stenosis of 5% or more were referred for renal angiography, the number of referrals was reduced by 20%, while 9% of patients with a stenosis were missed. CONCLUSIONS: The prediction rule was valid in more recently treated patients in other settings. If used conservatively, the rule can reliably exclude a small proportion of patients from angiography.

Accuracy of computed tomographic angiography and magnetic resonance angiography for diagnosing renal artery stenosis.

BACKGROUND: Timely, accurate detection of renal artery stenosis is important because this disorder may be a potentially curable cause of hypertension and renal impairment. OBJECTIVE: To determine the validity of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA) compared with digital subtraction angiography (DSA) for detection of renal artery stenosis. DESIGN: Prospective multicenter comparative study conducted from 1998 to 2001. Two panels of 3 observers judged CTA and MRA image data and were blinded to all other results. Digital subtraction angiography images were evaluated by consensus. SETTING: 3 large teaching hospitals and 3 university hospitals in the Netherlands. PATIENTS: 402 hypertensive patients with suspected renal artery stenosis were included. A group of 356 patients who underwent all 3 diagnostic tests was used for analysis. MEASUREMENTS: Reproducibility was assessed by calculating interobserver agreement. Diagnostic performance was evaluated in terms of sensitivity, specificity, and other diagnostic variables. Atherosclerotic stenoses of 50% or greater and fibromuscular dysplasia were considered clinically relevant. RESULTS: Twenty percent of patients who underwent all 3 tests had clinically relevant renal artery stenosis. Moderate interobserver agreement was found, with kappa values ranging from 0.59 to 0.64 for CTA and 0.40 to 0.51 for MRA. The combined sensitivity and specificity were 64% (95% CI, 55% to 73%) and 92% (CI, 90% to 95%) for CTA and 62% (CI, 54% to 71%) and 84% (CI, 81% to 87%) for MRA. LIMITATIONS: Eighteen percent of the patients were included nonconsecutively. Digital subtraction angiography may be an imperfect reference test. CONCLUSION: Computed tomographic angiography and MRA are not reproducible or sensitive enough to rule out renal artery stenosis in hypertensive patients. Therefore, DSA remains the diagnostic method of choice. *For a list of the other investigators and research coordinators who participated in RADISH, see the Appendix.