A clinical training unit for diarrhoea and acute respiratory infections: an intervention for primary health care physicians in Mexico.

In Tlaxcala State, Mexico, we determined that 80% of children who died from diarrhoea or acute respiratory infections (ARI) received medical care before death; in more than 70% of the cases this care was provided by a private physician. Several strategies have been developed to improve physicians' primary health care practices but private practitioners have only rarely been included. The objective of the present study was to evaluate the impact of in-service training on the case management of diarrhoea and ARI among under-5-year-olds provided by private and public primary physicians. The training consisted of a five-day course of in-service practice during which physicians diagnosed and treated sick children attending a centre and conducted clinical discussions of cases under guidance. Each training course was limited to six physicians. Clinical performance was evaluated by observation before and after the courses. The evaluation of diarrhoea case management covered assessment of dehydration, hydration therapy, prescription of antimicrobial and other drugs, advice on diet, and counselling for mothers; that of ARI case management covered diagnosis, decisions on antimicrobial therapy, use of symptomatic drugs, and counselling for mothers. In general the performance of public physicians both before and after the intervention was better than that of private doctors. Most aspects of the case management of children with diarrhoea improved among both groups of physicians after the course; the proportion of private physicians who had five or six correct elements out of six increased from 14% to 37%: for public physicians the corresponding increase was from 53% to 73%. In ARI case management, decisions taken on antimicrobial therapy and symptomatic drug use improved in both groups; the proportion of private physicians with at least three correct elements out of four increased from 13% to 42%, while among public doctors the corresponding increase was from 43% to 78%. Hands-on training courses thus seemed to be effective in improving the practice of physicians in both the private and public sectors.

PIP: This study evaluated the impact of an in-service training course for physicians on diarrhea and acute respiratory infection (ARI) management in children under age 5 in Tlaxcala, Mexico, between January 1993 and April 1994. The training consisted of a 5-day course of in-service practice, during which physicians diagnosed and treated sick children attending a center and conducted clinical discussions of cases under guidance. Each training course was limited to 6 physicians. Clinical performance was evaluated by observation before and after the courses. The evaluation of diarrhea case management covered assessment of dehydration, hydration therapy, prescription of antimicrobial and other drugs, advice on diet, and counseling of mothers. The evaluation of ARI case management, on the other hand, covered diagnosis, decisions on antimicrobial therapy, use of symptomatic drugs, and counseling of mothers. The study revealed that the performance of public physicians before and after the intervention was better compared to those of private doctors. Most aspects of case management of children with diarrhea improved among both groups of physicians after the course. The proportion of private doctors who had 5 or 6 correct elements out of 6 increased from 14% to 37%, while for public doctors the corresponding increase was from 53% to 73%. As for the ARI case management, decisions taken on antimicrobial therapy and symptomatic drug use improved in both groups. The proportion of private physicians with at least 3 correct elements out of 4 increased from 13% to 42%, while among the public doctors, the corresponding increase was from 43% to 78%.

[Critical reading in selected groups of medical students]. / Lectura crítica en grupos escogidos de estudiantes de medicina.

BACKGROUND: The shaping of professionals with a critical outlook in their field of endeavor is a goal of some educational institutions in our country. However, little participation from the students is demanded in our medical schools and this probably interferes in the development of skills for critical reading. OBJECTIVE: To evaluate critical reading in medical students with high scholastic achievement as a function of years of medical training. MATERIAL AND METHODS: We studied three groups of medical students who were homogeneous in regard to scholastic achievement (their mean was 9 or higher in a scale of 10). The groups were in the first, third and fifth year of their medical training (N was 24, 15 and 12 respectively). Two homogeneous groups of low achievers (mean of 7 or less in their first year of training with N of 20 and 16) were also included as contrast groups (no homogeneous groups of low achievers were present in higher years). The test applied was elaborated by us and has been validated. It evaluates reading comprehension (30 items) and interpretation (40 items) of medical information with questions to be answered true/false/don't know and which are scored -1 (incorrect), zero (don't know) or 1 (correct). The scores were analyzed using non-parametric techniques. We consider reading interpretation as a capacity better representing critical reading. RESULTS: In the three groups of high achievers, comprehension was the same (median of 26 out of a maximum of 30) and interpretation ranged from 21.5 to 23 with no group differences (Kruskal-Wallis test). The high achievers had significantly higher scores in reading and interpretation than the low achievers (U test p < 0.01). There was also a consistent higher score of comprehension over interpretation in the five groups (chi square of proportions p < 0.01) but the association of comprehension and interpretation was present only in three groups (high achievers in 1st and 3d year and low in 1st with correlations of Spearman ranging from 0.43 to 0.56). CONCLUSIONS: We were unable to detect any significant difference of years of medical training in the ability to comprehend or interpret medical information. We were able to detect differences in these abilities between high and low achievers.

[Systemic-psychodynamic model for family evaluation]. / Modelo psicodinámico-sistémico de evaluación familiar.

In this paper a family evaluation instrument called systemic-psychodynamic family evaluation model is described. Also, the second stage of the validation study of this instrument is presented (which deals with the inter-observers variation). Twenty families were studied. They were assessed always by the same interviewers designated as experts. They are all family therapy specialists and their assessment was used as the evaluation reference standard or "gold standard". The observers were psychiatrists without previous training in family therapy. For the purpose of the interview, both experts and observers were blind to the medical diagnosis of the patients. During the first stage of the validation study the observers did not have a reference guide which resulted in a low concordance rating. For the second stage, a 177 item guide was used and a considerable increase in the concordance rating was observed. Validation studies like the one used here are of considerable value to increase the reliability and further utilisation of evaluation instruments of this type.

[New approaches to the measurement of clinical competence]. / Nuevas aproximaciones a la medición de la competencia clínica.

A new phase in the development of an instrument designed for the measurement of clinical competence is presented. The instrument (exam type) was previously validated; we report its use in three generations of students of a specialization course in internal medicine: those recently admitted to the course (group I); those finishing their first training year (group II) and those finishing the second year (group III). In the exam 304 out of the 600 questions included were classified as "experimental" (dealing with knowledge in internal medicine) and the remaining 296 questions corresponded to "control" questions (dealing with knowledge in other specialties). The variables considered in the exam were: 1) global result; 2) usage of diagnostic indicators; 3) omission of necessary procedures without a iatrogenic effect; 4) commission of unnecessary procedures without a iatrogenic effect; 5) omission of necessary procedures with resulting iatrogenic consequences; 6) commission of unnecessary procedures with resulting iatrogenic consequences; 7) global omission (variables 3 and 5); 8) global commission (variables 4 and 6); 9) global iatrogenesis (variables 5 and 6); 10) knowledge in nosology. Scores obtained by the three groups on the experimental questions differed in accordance with the respective time of clinical experience (group I obtained the lowest scores, group II showed intermediate scores, and group III showed the highest scores). Analysis of variance was significant (p less than 0.05) in variables 1, 2, 6, 8 and 9. The scores obtained by the three groups on the control questions were similar. In conclusion, we believe that this instrument is capable of detecting learning dependent on the time of clinical experience.(ABSTRACT TRUNCATED AT 250 WORDS)

[The challenge of evaluating clinical competence]. / El desafío de la evaluación de la competencia clínica.

The study is divided in two parts. The first one deals with theoretical aspects of evaluation. In the second part, the development of an instrument intended to explore clinical competence is presented. The importance of considering evaluation as part of a research process is emphasized in the first part. The diverse theoretical and action trends in the field of education are synthetized in two main tendencies: the active-participating and the passive-receptive. The influence of these two tendencies in the selection the objects for evaluation is also discussed. An evaluation instrument developed by us to explore clinical competence is placed within the active-participating tendency of education; the present state of this instrument is given in the second part. The instrument consists of multiple choice options of the true, false, don't know type. The instrument in its present version is the result of a long validation process. It explores particularly iatrogenic behaviors by omission or commission. The sample studied were 457 applicants for specialization courses in medicine. Of these, 127 were foreign applicants. The instrument was applied to the whole sample in one single session. The results showed a low general clinical competence, with similar results in mexican and foreign applicants. A clear difference was found in commission iatrogenia which was significantly more frequent than omission iatrogenia. The theoretical superiority of our test in relation the others is discussed.

[Iatrogenic trends as indicator of clinical competence in courses of specialization in medicine]. / Tendencias iatrogénicas como indicador de competencia clínica en los cursos de especialización en medicina.

Iatrogenesis, understood here as an unfavourable effect to the health of patients provoked by the medical institution, has risen little interest in the researchers of the health area in spite of its growing presence. The present study had the aim of exploring the iatrogenic behavior of 659 recently graduated physicians by a questionnaire composed by clinical cases which described diagnostic and/or therapeutic situations that required the making of decisions. The questionnaire consisted of 600 general medical knowledge questions of which 112 explored commission of iatrogenic behavior. The group showed a iatrogenicity index of 39.5% ranging between 15.2% and 74.1%. When this iatrogenicity index was compared to that of global medical knowledge (600 questions) no correlation was found. It is concluded that the "iatrogenicity" index of this group is high and lacks correlation with the global medical knowledge. This suggests that the individualized and careful use of the diagnostic and therapeutic resources suitable for specific situations in patients does not receive sufficient emphasis during the teaching-learning process nor does it play a prominent role within the priorities of knowledge that are learned in the school of medicine. The need to deepen our understanding of the iatrogenic behavior of the physicians at different levels of their professional training is emphasized.

[Involuntary weight loss as a clinical problem]. / La pérdida ponderal involuntaria como problema clínico.

Weight loss can herald the existence of an underlying serious disease. The purpose of this study was to ascertain the frequency of the involuntary weight loss at the Internal Medicine inpatient service of our Institution and the different conditions associated with it. The study was undertaken from March 1984 to February 1985. All patients who had lost at least 10% of their total body weight 6 months prior to admission were included. Those patients who had an evident organic disease, which could explain their weight loss, were excluded. A complete clinical history was performed in all cases; additional data concerning family and employment aspects and symptoms of depression were recorded. The evaluation also included screening laboratory examinations and specific diagnostic procedures. The study group consisted of 50 patients, 32 males and 18 females whose average age was 57.6 and 62.5 years, respectively. Mean average percentage of weight loss was 19%. The involuntary weight loss turned out to be clearly related to an organic cause in only 17 patients (34%), five of which had a malignant neoplasm. On the other hand, in 21 cases, factors such as stress inductors and depression seemed directly related to the involuntary weight loss. It is concluded that malignant diseases are not the pathology most frequently associated with unexplained involuntary weight loss in our Institution. Differential diagnosis must consider other organic and psychiatric disorders. Particular attention should be paid to those data relative to dietary habits, the patient's family and symptoms of depression in order to attain a more integral view of the patients.