Using standardized video cases for assessment of medical communication skills: reliability of an objective structured video examination by computer.

OBJECTIVE: Using standardized video cases in a computerized objective structured video examination (OSVE) aims to measure cognitive scripts underlying overt communication behavior by questions on knowledge, understanding and performance. In this study the reliability of the OSVE assessment is analyzed using the generalizability theory. METHODS: Third year undergraduate medical students from the Academic Medical Center of the University of Amsterdam answered short-essay questions on three video cases, respectively about history taking, breaking bad news, and decision making. Of 200 participants, 116 completed all three video cases. Students were assessed in three shifts, each using a set of parallel case editions. About half of all available exams were scored independently by two raters using a detailed rating manual derived from the other half. Analyzed were the reliability of the assessment, the inter-rater reliability, and interrelatedness of the three types of video cases and their parallel editions, by computing a generalizability coefficient G. RESULTS: The test score showed a normal distribution. The students performed relatively well on the history taking type of video cases, and relatively poor on decision making and did relatively poor on the understanding ('knows why/when') type of questions. The reliability of the assessment was acceptable (G = 0.66). It can be improved by including up to seven cases in the OSVE. The inter-rater reliability was very good (G = 0.93). The parallel editions of the video cases appeared to be more alike (G = 0.60) than the three case types (G = 0.47). DISCUSSION: The additional value of an OSVE is the differential picture that is obtained about covert cognitive scripts underlying overt communication behavior in different types of consultations, indicated by the differing levels of knowledge, understanding and performance. The validation of the OSVE score requires more research. CONCLUSION AND PRACTICE IMPLICATIONS: A computerized OSVE has been successfully applied with third year undergraduate medical students. The test score meets psychometric criteria, enabling a proper discrimination between adequately and poorly performing students. The high inter-rater reliability indicates that a single rater is permitted.

Assessment of medical communication skills by computer: assessment method and student experiences.

BACKGROUND: A computer-assisted assessment (CAA) program for communication skills designated ACT was developed using the objective structured video examination (OSVE) format. This method features assessment of cognitive scripts underlying communication behaviour, a broad range of communication problems covered in 1 assessment, highly standardised assessment and rating procedures, and large group assessments without complex organisation. SETTING: The Academic Medical Centre (AMC) at the University of Amsterdam, the Netherlands. Aims To describe the development of the AMC Communication Test (ACT); to describe our experiences with the examination and rating procedures; to present test score descriptives, and to present the students' opinions of ACT. DESIGN: The ACT presents films on history taking, breaking bad news and shared decision making. Each film is accompanied by 3 types of short essay questions derived from our assessment model: "knows", "knows why/when" and "knows how". Evaluation questions about ACT were integrated into the assessment. Participants A total of 210 third year medical undergraduates were assessed. This study reports on the 110 (53%) students who completed all evaluation questions. RESULTS: Marking 210 examinations took about 17 days. The test score matched a normal distribution and showed a good level of discrimination of the students. About 75% passed the examination. Some support for the validity of our assessment model was found in the students' differential performance on the 3 types of questions. The ACT was well received. Student evaluations confirmed our efforts to develop realistic films that related well to the communication training programme. CONCLUSIONS: The ACT is a useful assessment method which complements interpersonal assessment methods for the evaluation of the medical communication skills of undergraduates.

The meaning of urgency in the allocation of scarce health care resources; a comparison between renal transplantation and psychogeriatric nursing home care.

In the juridical and ethical literature on patient selection criteria it is an unargued premise that those who are most urgently in need of treatment or care will be given priority. The aim of this study is to gain insight into the medical practice of waiting list problems and patient selection at the microlevel, especially with respect to urgency. Thus, the study intends to contribute to the medical ethical discussion on patient selection for scarce resources. The results of qualitative research into the meaning and occurrence of urgency in two health care services, renal transplantation and psychogeriatric nursing home care, are discussed. In the first sector, patients are seldom considered urgent. Criteria for urgency are technical dialysis problems or severe psychological burden due to protracted dialysis treatment. In contrast, psychogeriatric patients are often considered urgent, with the principal criterion being too heavy a care load for informal carers. Both health care services show variation in assigning urgency codes. It appears that the exact meaning of urgency is not self-evident and that admission of urgent patients to nursing homes can be negotiated by professionals or informal carers. This points to the necessity of a discussion within these services as to the actual content matter of urgency. Further, professionals involved in renal transplantation raise several moral and practical arguments against giving patients priority, even if they need treatment urgently. It shows that distributive justice cannot always be applied. Occasionally non-urgent patients are rated urgent as they have been waiting very long due to specific allocation procedures. In these cases urgency is granted in an unexpected way that is ultimately in accordance with the notion of procedural justice.

[Variation in reporting of available places in the neonatal intensive care units and consequences for efficiency, fairness and quality of care]. / Variatie in aanmelding van vrije plaatsen door neonatale intensive-careafdelingen en consequenties voor doelmatigheid, rechtvaardigheid en kwaliteit van zorg.

OBJECTIVE: To determine whether the national information system on available beds in neonatal intensive care units (NICUs) leads to fair distribution and good efficiency and quality of care. SETTING: Two out of the ten NICUs in the Netherlands. DESIGN: Descriptive. METHODS: Data were gathered through observations and 18 interviews with among others neonatologists, gynaecologists and paediatricians. Another 19 doctors were interviewed by phone after a patient they had referred was refused. Interviews were analysed by means of Kwalitan, a computer programme for analysis of qualitative research. RESULTS: When a patient could not be admitted in his own region, the information system was often used to find out which NICUs had a bed available. Sometimes a NICU was called that, according to the information system, did not have a place available. Reasons were: the information was not up to date and not all available beds were reported. This last reason had to do with the wish to keep a bed free for patients from the NICU's own region. Because most doctors were aware of this, they sometimes negotiated about beds, which was time-consuming. CONCLUSION: The information system was used often, but was working below optimal level, resulting in diminished efficiency. This was primarily caused by the priority given to patients of the own region, which had to do with quality of care considerations. The existing variation in use of the priority policy deserves attention from the viewpoint of procedural justice.

The use of the waiting list in a fair selection of patients for nursing home care.

When health care resources are scarce, waiting lists may be used as a distribution measure in order to enhance the fair allocation of resources through selection of patients. In this study, the structure and use of a waiting list for a fair selection of patients for nursing home admission was studied. Qualitative research took place in two regions in the Netherlands, where scarcity exists in nursing home care. Selection meetings were attended and 39 health care workers were interviewed. Not only did waiting list criteria like urgency and chronology determine the final selection decision, but also efficiency and quality of care considerations (patients' preferences for particular nursing homes and nursing homes' considerations of matching the unit and work load). These considerations, their relative importance, and the resulting need for enforcement of the decision-making procedures, should be part of the discussion of patient selection. This acknowledges the complexity of the selection of patients.

Doctor-patient communication: a review of the literature.

Communication can be seen as the main ingredient in medical care. In reviewing doctor-patient communication, the following topics are addressed: (1) different purposes of medical communication; (2) analysis of doctor-patient communication; (3) specific communicative behaviors; (4) the influence of communicative behaviors on patient outcomes; and (5) concluding remarks. Three different purposes of communication are identified, namely: (a) creating a good inter-personal relationship; (b) exchanging information; and (c) making treatment-related decisions. Communication during medical encounters can be analyzed by using different interaction analysis systems (IAS). These systems differ with regard to their clinical relevance, observational strategy, reliability/validity and channels of communicative behavior. Several communicative behaviors that occur in consultations are discussed: instrumental (cure oriented) vs affective (care oriented) behavior, verbal vs non-verbal behavior, privacy behavior, high vs low controlling behavior, and medical vs everyday language vocabularies. Consequences of specific physician behaviors on certain patient outcomes, namely: satisfaction, compliance/adherence to treatment, recall and understanding of information, and health status/psychiatric morbidity are described. Finally, a framework relating background, process and outcome variables is presented.