Do poor patients suffer from inaccurate diagnoses more than well-to-do patients? A randomized control trial.

BACKGROUND: Poor patients have greater morbidity and die up to 10 years earlier than patients who have higher socio-economic status. These findings are often attributed to differences in life-style between groups. The present study aimed at investigating the extent to which physicians contribute to the effect by providing relative poorer care, resulting in relative neglect in terms of time spent with a poor patient and more inaccurate diagnoses. METHODS: A randomised experiment with 45 internal medicine residents. Doctors diagnosed 12 written clinical vignettes that were exactly the same except for the description of the patients' socio-economic status. Each participant diagnosed four of the vignettes in a poor-patient version, four in a rich-patient version, and four in a version that did not contain socio-economic markers, in a balanced within-subjects incomplete block design. Main measurements were: diagnostic accuracy scores and time spent on diagnosis. RESULTS: Mean diagnostic accuracy scores (range 0-1) did not significantly differ among the conditions of the experiment (for poor patients: 0.48; for rich patients: 0.52; for patients without socio-economic markers: 0.54; p > 0.05). While confronted with patients not presenting with socio-economic background information, the participants spent significantly less time-to-diagnosis ((for poor patients: 168 s; for rich patients: 176 s; for patients without socio-economic markers: 151 s; p < 0.01), however due to the fact that the former vignettes were shorter. CONCLUSION: There is no reason to believe that physicians are prejudiced against poor patients and therefore treat them differently from rich patients or patients without discernible socio-economic background.

Clinical Learning Evaluation Questionnaire: A Confirmatory Factor Analysis.

INTRODUCTION: The Clinical Learning Evaluation Questionnaire (CLEQ) is a multidimensional, reliable instrument designed to measure the effectiveness of the clinical learning environment for undergraduate medical students. This study seeks to measure and examine the underlying construct along with the latent variables by conducting a confirmatory factor analysis, using structural equation modeling (SEM) so that the instrument can be utilized as an evaluation tool for the continuous improvement of educational environments and curricula. METHODS: A cross-sectional study was carried out on 185 third- and fourth-year medical students. A confirmatory factor analysis was conducted, beginning with principal component analysis for standardized factor loadings, using varimax rotation in SPSS to explore the underlying construct of items. The constructs to which each item was tied were determined, and then the data were run through AMOS to assess construct validity through item reduction based on the modification indices, and estimates were made of the standardized residual covariance of each item in order to determine the best model fit. RESULTS: A total of 185 students completed the CLEQ Inventory. The original six-factor structure of the CLEQ did not achieve model fit (X2=1587.475, RMSEA=0.092, RMR=0.146, GFI=0.651, AGFI=0.601, CFI=0.728, NFI=0.626). However, the suggested four-factor model of CLEQ displayed good model fit with the improvement of values (X2=86.184, RMSEA=0.052, RMR=0.062, GFI=0.903, AGFI=0.865, CFI=0.951, NFI=0.871). Internal consistency analysis showed that Cronbach's alpha values of the original six-factor model ranged from 0.68 to 0.88, while four-factor model ranged from 0.72 to 0.87. CONCLUSION: This study did not support the proposed six-factor structure of the CLEQ tool. However, the four-factor CLEQ structure demonstrated an adequate degree of good fit and was found to be as reliable as the original structure. Further research on the predictive validity of CLEQ is required as well as a comparison of the psychometric properties across different institutions and countries.

Risk of diagnostic errors when dealing with aggressive patients: Experimental study.

Medical errors are still common despite advances in technology and policies to insure patients' safety. They can be traceable as in medications or surgical errors, but may not be so in diagnostic errors that are patient, physician, or system related. This study aimed to explore whether aggressive behavior of some patients might affect physicians' clinical reasoning and decision-making. The study was conducted in a format of observation skills clinical examinations (OSCEs). It included simulating patients (SPs) and family physicians in residency training in a clinical setup. The experiment included two arms of dealing with case scenarios with "Neutral" and "Aggressive" behaviors. Explanatory variables assessed were duration of consultation, correct diagnosis, and plan of appropriate management as well as patients' satisfaction. Participants were 14 trained SPs who played the roles of aggressive and nonaggressive patients when they encountered 35 residents (18 were males) in family physicians [year 2 (R2), year 3 (R3) and year 4 (R4)]; in a total of seventy patient/doctor encounters. Compared with nonaggressive patients, aggressive patients had statistically significantly prolonged OSCE duration [mean (standard deviation) = 6.89 (1.35) and 6.11 (157) min, respectively; P = 0.031] and more patient consultation satisfaction (P <0.0001). However, no statistically significant differences were found in diagnostic accuracy (P = 0.626) and management (P = 0.621). In a stratified analysis, junior doctors had longer duration of consultation and seemed to perform better in management (higher patient satisfaction and better management outline) than their senior counterparts. Patients' aggressive behavior led to longer duration of medical consultation. Poor management plan, albeit correct diagnosis, in senior doctors may be due to disruptive clinical reasoning in disturbed stressful situation. Coping strategies should be emphasized in medical education to ensure effective clinical reasoning in patient/doctor encounters.

Barriers to feedback in undergraduate medical education. Male students' perspective in Central Saudi Arabia.

OBJECTIVE: To explore the views of undergraduate medical students regarding the presence and sources of barriers to effective feedback in their setting. METHODS: This cross-sectional study was conducted at the College of Medicine, Department of Medical Education, King Saud bin Abdul-Aziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia from April to June 2010. A self-administered questionnaire was used to explore the objectives of the study. RESULTS: One hundred and eighty-six male undergraduate medical students participated in this study. Approximately 45% indicated presence of barriers to effective feedback. These include: absence of a clear system of feedback; inadequate skills of teachers for provision-effective feedback; and to a lesser extent, students' fear of insult due to feedback. Most participants showed their interest and readiness to receive more professional feedback in the future. CONCLUSION: This study has showed the presence of barriers as perceived by medical students, which could significantly minimize utilization of feedback in medical education. The reported barriers should be addressed to utilize the vital role of feedback in the learning process of undergraduate medical students.

Perception among medical students in Riyadh, Saudi Arabia, regarding alcohol and substance abuse in the community: a cross-sectional survey.

BACKGROUND: This study was conducted to examine the perception and views of medical students regarding the extent of alcohol and substance abuse in the community and the possible predisposing factors for this problem. METHODS: It is a cross-sectional study involving samples from two medical colleges in Riyadh, Saudi Arabia. The students who decided to participate in the study without the offer of any incentives filled an anonymous, self administered questionnaire which had been designed to meet the purpose of the study. RESULTS: Two hundred and fifteen out of three hundred and thirty students (65% response rate) participated in this study. About 75% of them believe that alcohol and substance abuse is a common problem in the community. Students' views also correspond with the reported view that the problem is mainly present in young adult males. Married males and senior students perceived the problem as more serious than their other colleagues. Students perceived that alcohol was the most commonly abused drug in the community, followed by amphetamines, heroin, cannabis and cocaine. They believe that influence of friends, life stressors, tobacco smoking and curiosity are the most important predisposing factors for abuse of alcohol and other substances. According to the students' perception, the main beneficial effect of alcohol and substance abuse was stress alleviation. About 3% of the students have also indicated that they may use alcohol or some other substance in the future. CONCLUSION: Despite scarce information on the subject and a strong religious belief in Saudi Arabia against the use of alcohol and other addictive substances, a significant majority of the medical students in Riyadh, the capital of Saudi Arabia, perceived that alcohol and substance abuse is a common problem in the community. Some students appear to perceive the seriousness of the problem less than others. Efforts are needed to educate young men and women at an early stage of their academic life, as a medical student about the existence of this problem in the community, its consequences and predisposing factors. Teaching teenagers and young adults about stress coping strategies may be of special importance in reducing the risk of alcohol and substance abuse.

Medical students' evaluation of their exposure to the teaching of ethics.

BACKGROUND: The subject of Biomedical Ethics has become recognized as an essential integral component in the undergraduate curriculum of medical students. OBJECTIVES: (1) To review the current Biomedical Ethics Course offered at the College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences (KSAU-HS). (2) To explore the perception of medical students on the different components of the course. MATERIALS AND METHODS: The medical students were requested to participate in the study at the end of the course by filling in a pre-designed questionnaire. A qualitative approach was used also to examine their perceptions about certain components of the course. RESULTS: Forty-one medical students participated in this study. All students expressed their strong agreement on the importance of their learning biomedical ethics. Their views about the role of Biomedical Ethics were also considered. These include professional development, assessment of ethical competencies, and the timing of the teaching of ethics. CONCLUSION: The students provided valuable comments that were supported by the literature reviews. Medical Students' views of the teaching of the various components of biomedical ethics are important and should be sought in the planning of a curriculum.

Knowledge, attitude and practice of tobacco smoking by medical students in Riyadh, Saudi Arabia.

BACKGROUND: Tobacco consumption is associated with considerable negative impact on health. Health professionals, including future doctors, should have a leading role in combating smoking in the community. OBJECTIVES: The aims of the study were to assess the prevalence of smoking among medical students of newly established medical colleges in Riyadh city, the capital of Saudi Arabia, as well as to assess students' attitude, practice and their knowledge on the risk factors of tobacco consumption. METHODS: A cross-sectional, questionnaire-based study of students from two medical colleges in Riyadh, Saudi Arabia was carried out. The questionnaire used was anonymous, self-administered and developed mainly from Global Adult Tobacco Survey (GATS). RESULTS: A total of 215 students participated in this study. Forty students (19%) indicated that they smoke tobacco at the time of the study. All of them were males, which raise the prevalence among male students to 24%. Tobacco smoking was practiced by males more than females (P value <0.0001) and by senior more than junior students (<0.0001). About 94% of the study sample indicated that smoking could cause serious illnesses. About 90% of the students indicated that they would advice their patients to quit smoking in the future and 88% thought that smoking should be banned in public areas. Forty-four students (20%) thought that smoking has some beneficial effects, mainly as a coping strategy for stress alleviation. CONCLUSION: Despite good knowledge about the hazards of tobacco consumption, about 25% of the medical students in this study continue to smoke. The main reported reasons should be addressed urgently by policy-makers. Special efforts should be taken to educate medical students on the effective strategies in managing stress during their study as they thought that tobacco smoking could be used as a coping strategy to face such a stress.

Appointment system in primary care: opinion of consumers and providers.

BACKGROUND: The appointment system in primary care is widely used in developed countries, but there seems to be a problem with its use in Saudi Arabia. OBJECTIVES: (1) To explore opinions and satisfaction of consumers and providers of care in Primary Health Care regarding walk-in and the introduction of the appointment system. (2) To examine factors which may affect commitment to an appointment system in PHC. SUBJECT AND METHOD: Two hundred sixty (260) consumers above the age of 15 years as well as seventy (70) members of staff were randomly selected from 10 Primary Health Care Clinics in the National Guard Housing Area, Riyadh and asked to complete a structured questionnaire designed to meet the study's objectives. RESULTS: The majority of consumers and providers of care were in favour of introducing appointments despite their satisfaction with the existing walk-in sysem. Respondents saw many advantages in the appointment system in PHC such as time saving, reduction of crowds in the clinics and guarantee of a time slot. The main perceived disadvantage was the limitation of accessibility to patients especially with acute conditions. The main organizational advantages and disadvantages perceived by providers were related to follow-ups of chronic patients, no shows and late arrivals. The majority of the patients preferred appointments in the afternoon and the possibility of obtaining an appointment over the telephone. CONCLUSION: In this study, both consumers and providers supportted the idea of introducing the appointment mixed system in primary care, but further study is required.