Selecting performance assessment methods for experienced physicians.

BACKGROUND: While much is now known about how to assess the competence of medical practitioners in a controlled environment, less is known about how to measure the performance in practice of experienced doctors working in their own environments. The performance of doctors depends increasingly on how well they function in teams and how well the health care system around them functions. METHODS: This paper reflects the combined experiences of a group of experienced education researchers and the results of literature searches on performance assessment methods. CONCLUSION: Measurement of competence is different to measurement of performance. Components of performance could be re-conceptualised within a different domain structure. Assessment methods may be of a different utility to that in competence assessment and, indeed, of different utility according to the purpose of the assessment. An exploration of the utility of potential performance assessment methods suggests significant gaps that indicate priority areas for research and development.

Towards an acceptance of performance assessment.

The utility of any assessment tool critically depends on its level of acceptance by those on whom the assessment impacts. Performance assessment impacts on three distinct groups: patients/consumers, doctors and employers. While these groups may have conflicting beliefs and expectations of performance assessment, the process must be made acceptable to all. This can happen through an exploration of the beliefs and wishes of the key stakeholders in relation to performance assessment, together with the potential rewards and costs. This paper draws on the psychology literature in describing an effective model for change management. It outlines some strategies for each of the three key elements of any successful strategy for change, i.e. getting started, facilitating the transition and ensuring consolidation. Such a practical approach will foster the acceptance of performance assessment structures among all stakeholders.

Physical activity and cardiovascular risk factors: effect of advice from an exercise specialist in Australian general practice.

OBJECTIVE: To determine whether provision of individualised physical activity advice by an exercise specialist in general practice is effective in modifying physical activity and cardiovascular risk factors in older adults. DESIGN: Randomised controlled trial of individualised physical activity advice, reinforced at three and six months (intervention) versus no advice (control). SETTING: Two general practices in Adelaide, South Australia, 1996. PARTICIPANTS: 299 adults aged 60 years or more who were healthy, sedentary and living in the community. MAIN OUTCOME MEASURES: Changes to physical activity (frequency and duration of walking and vigorous exercise), selected cardiovascular risk factors (blood pressure, body weight, serum lipid levels) and quality of life over 12 months. RESULTS: Self-reported physical activity increased over the 12 months in both groups (P < 0.001). The increase was greater for the intervention than the control group for all measures except time spent walking (P < 0.05). More intervention than control participants increased their intention to exercise (P < 0.001). Serum levels of total and low-density lipoprotein cholesterol and triglycerides fell significantly over the 12 months to a similar extent in the two groups. No other significant changes in cardiovascular risk factors were seen. Quality-of-life scores decreased over the 12 months. The decrease was significantly greater among intervention than control women, but not men, for emotional well-being (P = 0.02), physical well-being (P = 0.04) and social functioning (P = 0.04). DISCUSSION: Provision of general practice-based physical activity advice reinforced three-monthly produced a sustained increase in self-reported physical activity. However, there were no associated changes in clinical measures of cardiovascular risk factors and minimal changes in quality-of-life measures.

Profile of people referred to an emergency department from residential care.

BACKGROUND: Elderly people in residential care are among the most infirm in society and are at high risk of developing acute medical problems. There are no Australian data on the use of acute hospital emergency services by this group. AIM: To determine patterns of use of a major public hospital's Emergency Department (ED) by elderly people living in residential care, their presenting problems and the outcome of attendance. METHODS: Prospective study of 300 consecutive referrals to a teaching hospital's ED involving people aged over 65 years and living in residential care in southern Adelaide, South Australia. Case records were examined and residential care staff were interviewed by telephone when information required clarification. This occurred in 25% of referrals. RESULTS: The 300 referrals were seen over a three month period and accounted for 2.43% of the 12,371 ED attendances during this period. During this time, at least 4.9% of people in residential care in the region were referred to the ED. The referrals involved 239 residents, 196 (82%) who were referred once only, 32 (13%) twice and 11 (5%) three or more times. Residents had a mean age of 84 years and 70% were female. A broad range of acute medical problems precipitated referral and 61% of people referred were immediately hospitalised. There was no general practitioner (GP) involvement in the management of the presenting illness in 58% of all referrals and in 45% of those where symptoms had been present for over three days. CONCLUSIONS: People living in residential care are frequently referred to an ED service, often bypassing their GP in the process. They present with a wide range of acute medical problems for which most are hospitalised. Strategies that anticipate, prevent and manage health breakdown in residential care and so minimise the need for ED referral should be trialed.

Problem-based learning: its rationale and efficacy.

Problem-based learning (PBL) in medical education uses clinical cases as the context for students to study basic and clinical sciences. Its possible advantages over traditional approaches include its greater relevance to the practice of medicine, its ability to promote retention and application of knowledge, and its encouragement of self-directed life-long learning. Possible disadvantages include higher costs, both in resources and staff time. Although its efficacy is difficult to evaluate, the current enthusiasm for PBL seems justified and its use is likely to increase further.

Use of inpatient hospital services by people aged 90-99 years.

OBJECTIVE: To examine the use of inpatient hospital services by people aged 90-99 years. DESIGN: Retrospective case note review. SETTING: Flinders Medical Centre, a 516-bed university teaching hospital in Adelaide, South Australia. PATIENTS: All patients aged 90-99 years on the separation register for 1995. MAIN OUTCOME MEASURES: Patient demographic characteristics, principal diagnosis, length of hospital stay and outcome, including destination at discharge. RESULTS: In 1995, 317 separations involved 214 patients aged 90-99 years; 148 patients (69%) were admitted to hospital once, 43 (20%) twice and 23 (11%) three times or more. In 54% of separations, patients came from the community, and these were less likely to be emergency admissions (72%) than were admissions from hostels (87%) and nursing homes (93%). Patients had a wide range of acute medical and surgical problems and a median of five documented comorbidities. Patients survived to leave hospital in 290 separations (91%) and returned directly to their previous living circumstances in 212 (67%). Median hospital stay was 5.0 days, and in 25% of separations stay was one day or less. Patients admitted under the care of geriatricians had more emergency admissions (98%) and longer mean hospital stays (8.9 days) than those admitted under surgeons (69%; 5.9 days) or other physicians (66%; 5.0 days). CONCLUSION: Despite the acute nature of their illnesses and their multiple medical problems, most hospitalised nonagenarians in this study returned directly to their previous living circumstances after short hospital stays.

Acute mesenteric infarction in elderly patients.

The clinical features, the treatment given, the factors governing treatment selection, and the result of such treatment were analyzed in all patients aged 65 years and over in whom a tissue diagnosis of acute mesenteric infarction was made at a major teaching hospital. Thirty-two such patients, of mean age 78.5 years, were identified during the 8-year study period. Expected clinical features of bowel infarction were commonly absent; for example, there was no abdominal pain and no abdominal tenderness in 29% and 26% of patients, respectively. A sizeable minority of patients (29%) were acutely confused at presentation. All patients not undergoing surgery died shortly after admission to hospital. For those 20 patients (63%) who underwent abdominal surgery, half were discharged alive from hospital. Whether or not the patient survived was associated with the ward to which they were originally admitted. Those admitted to a surgical ward tended to be younger and had a more typical clinical presentation than their counterparts admitted to a medical ward. In particular they were more likely to have abdominal pain and distention and less likely to be confused. Surgical intervention was undertaken more often and earlier in those admitted to surgical wards and this may have accounted for the better outcome. It should be emphasized that acute mesenteric ischemia is a potentially correctable surgical condition even in very elderly people. A realization that the presentation is often atypical should increase the likelihood of early recognition and lead to improved patient survival.