Using the Many-Facet Rasch Model to analyse and evaluate the quality of objective structured clinical examination: a non-experimental cross-sectional design.

OBJECTIVES: Sources of bias, such as the examiners, domains and stations, can influence the student marks in objective structured clinical examination (OSCE). This study describes the extent to which the facets modelled in an OSCE can contribute to scoring variance and how they fit into a Many-Facet Rasch Model (MFRM) of OSCE performance. A further objective is to identify the functioning of the rating scale used. DESIGN: A non-experimental cross-sectional design. PARTICIPANTS AND SETTINGS: An MFRM was used to identify sources of error (eg, examiner, domain and station), which may influence the student outcome. A 16-station OSCE was conducted for 329 final year medical students. Domain-based marking was applied, each station using a sample from eight defined domains across the whole OSCE. The domains were defined as follows: communication skills, professionalism, information gathering, information giving, clinical interpretation, procedure, diagnosis and management. The domains in each station were weighted to ensure proper attention to the construct of the individual station. Four facets were assessed: students, examiners, domains and stations. RESULTS: The results suggest that the OSCE data fit the model, confirming that an MFRM approach was appropriate to use. The variable map allows a comparison with and between the facets of students, examiners, domains and stations and the 5-point score for each domain with each station as they are calibrated to the same scale. Fit statistics showed that the domains map well to the performance of the examiners. No statistically significant difference between examiner sensitivity (3.85 logits) was found. However, the results did suggest examiners were lenient and that some behaved inconsistently. The results also suggest that the functioning of response categories on the 5-point rating scale need further examination and optimisation. CONCLUSIONS: The results of the study have important implications for examiner monitoring and training activities, to aid assessment improvement.

Sociodemographic Variables, Clinical Features, and the Role of Preassessment Cross-Sex Hormones in Older Trans People.

INTRODUCTION: As referrals to gender identity clinics have increased dramatically over the last few years, no studies focusing on older trans people seeking treatment are available. AIMS: The aim of this study was to investigate the sociodemographic and clinical characteristics of older trans people attending a national service and to investigate the influence of cross-sex hormones (CHT) on psychopathology. METHODS: Individuals over the age of 50 years old referred to a national gender identity clinic during a 30-month period were invited to complete a battery of questionnaires to measure psychopathology and clinical characteristics. Individuals on cross-sex hormones prior to the assessment were compared with those not on treatment for different variables measuring psychopathology. MAIN OUTCOME MEASURES: Sociodemographic and clinical variables and measures of depression and anxiety (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self-Esteem Scale), victimization (Experiences of Transphobia Scale), social support (Multidimensional Scale of Perceived Social Support), interpersonal functioning (Inventory of Interpersonal Problems), and nonsuicidal self-injury (Self-Injury Questionnaire). RESULTS: The sex ratio of trans females aged 50 years and older compared to trans males was 23.7:1. Trans males were removed for the analysis due to their small number (n = 3). Participants included 71 trans females over the age of 50, of whom the vast majority were white, employed or retired, and divorced and had children. Trans females on CHT who came out as trans and transitioned at an earlier age were significantly less anxious, reported higher levels of self-esteem, and presented with fewer socialization problems. When controlling for socialization problems, differences in levels of anxiety but not self-esteem remained. CONCLUSION: The use of cross-sex hormones prior to seeking treatment is widespread among older trans females and appears to be associated with psychological benefits. Existing barriers to access CHT for older trans people may need to be re-examined.

Attitudes of patients with mild dementia and their carers towards disclosure of the diagnosis.

OBJECTIVE: To determine the attitudes of patients with mild dementia and their carers towards the disclosure of diagnoses of cancer and dementia and whether there are differences between these groups. To determine whether any major adverse events occurred following disclosure of diagnosis of dementia. DESIGN: A prospective study followed by a retrospective case-note study after 1 year. PARTICIPANTS AND SETTING: Fifty patients with mild dementia and their carers were recruited from a memory clinic in Nottingham, UK, and an old-age psychiatrist, using a semistructured questionnaire, separately interviewed them. MEASURES: Questions related to whether patients and their carers wished to be told diagnoses of cancer and dementia; the reasons for this; whether they would want treatment and make use of predictive testing if available were included. At 1-year follow-up whether antidepressants had been prescribed and whether any catastrophic reaction had occurred following disclosure of diagnosis. RESULTS: An overwhelming majority of patients with mild dementia wished to be informed of their diagnosis (92%); even more (98%) of the same patient sample reported wanting disclosure of a hypothetical diagnosis of cancer. A higher proportion (98%) of carers would wish to be told if they were to develop either dementia or cancer. All patients and carers would like access to treatment for dementia. A total of 88% of patients and 86% of carers would make use of a predictive test of Alzheimer's disease. Before receiving a diagnosis of mild dementia, only 28% of patients had insight that they may have dementia. Only a quarter (26%) of carers did not want the doctor to disclose the diagnosis of dementia to the patient. After 1 year, 6% of the original sample had developed a depressive illness requiring antidepressant treatment and no major incidents had occurred following disclosure of diagnosis. CONCLUSIONS: There has been a growing debate on whether patients with dementia should be informed of their diagnosis. Until recently, little was known about the views of patients themselves. This study shows that the vast majority of patients with mild dementia wish to be fully informed. Despite increasing awareness, a quarter of carers still do not wish their relative to be informed, though wish to be informed if they themselves were to develop the illness. This is significantly lower, however, than previously reported, suggesting a shift in attitudes. This study adds support to the weight of evidence that disclosure of a diagnosis of dementia does not cause depression or any irreversible harm to the patient.

To tell or not to tell: on disclosing the diagnosis of dementia.

Research suggests there has been a cultural change in the disclosure of diagnosis with most evidence held in cancer literature. This article reviews how disclosure of diagnosis relates to the field of dementia. Practitioners' attitudes and practice are being discussed, as are the attitudes and views of carers, peer groups, and patients. Practitioners show great variations in practice, with only around 50% of clinicians regularly telling patients with dementia their diagnosis. The majority of carers also appear to prefer the diagnosis to be withheld from the patient with dementia. However, most practitioners and carers would wish to know themselves if they had the illness. Although in contrast, studies on the views of elderly peer groups show that the vast majority wishes to be fully informed, views of patients with dementia regarding the area of disclosure are still lacking. Factors influencing the decision to disclose the diagnosis, including the degree of certainty of the diagnosis of dementia, the degree of insight of the patient, and the severity of the dementia, are investigated. The advantages and disadvantages of disclosure and the ethical issues are examined, as well as when or whether and how to disclose the diagnosis of dementia. Flexible guidelines regarding the process of disclosure are introduced.