The difficult patient: creation of a curriculum by third-year family practice residents.

BACKGROUND AND OBJECTIVES: Family practice residents tend to perceive psychosocial problems as less important than other factual aspects of their curriculum. To address this, we developed a problem-based learning (PBL) approach to the biopsychosocial model of medical care. METHODS: Third-year residents presented current problematic patients at a PBL advanced psychiatry conference. Data were collected on topics generated, resident attendance, and conference evaluation. RESULTS: The residents generated a topic list that closely matched a prior faculty-generated list. Some topics were discussed on multiple occasions; others not on the faculty list were also generated. Topics omitted were mental health in the physician's home, crisis prevention/intervention, and troubled marriages. In 1992-1995, resident attendance ranged from 56%-79%. A minority (0-5 residents) consistently attended fewer than 50% of the conferences. Residents evaluated the conference from "good" to "very good." CONCLUSIONS: By employing a PBL format and allowing residents to present current patients, conferences were better attended and covered almost all topics previously identified as important. PBL promoted efficient use of residents' time since residents were only required to research the literature about group knowledge deficits. This provided good training for the residents and excellent continuing medical education for faculty.

Chronic cough.

Chronic cough is defined as a cough that lasts for more than three weeks. More than 90 percent of cases of chronic cough result from five common causes: smoking, post-nasal drip, asthma, gastroesophageal reflux and chronic bronchitis. Although in most patients chronic cough has a single cause, in up to one fourth of patients, multiple disorders contribute to the cough. A stepwise evaluation in patients with chronic cough can minimize the invasiveness and expense of the work-up. Initial screening of patients with chronic cough should search for smoking, occupational exposure to an airway irritant, cough-inducing medications, airway hyperresponsiveness following upper respiratory infection, chronic bronchitis or any systemic symptoms suspicious for serious disease. Patients who are not diagnosed after an initial screening are evaluated or empirically treated in a stepwise fashion for postnasal drip, asthma and reflux. Bronchoscopy is reserved for use in the few patients still without a diagnosis after the previous steps have been completed.

Health care perceptions of the standardized patient.

As the use of standardized patients (SPs) for education and assessment continues to grow, there becomes an ever-increasing cohort of patients in our clinical practices who have participated as SPs. The present study is part of a five-year longitudinal study to examine the impact of participation as a standardized patient on the perceptions of the standardized patient's own health care. SPs participating in the 1993, 1994 and 1995 Objective Structured Clinical Examinations (OSCE) for medical students at the end of their third year were requested to respond to mailed questionnaires before, immediately after and one year after their participation in the OSCE(s). Results indicated that, while overall the SP's perceptions of their interactions with their doctors were positive both before and after participation in the OSCE, as a group, their perceptions of their own health care was significantly worse at one year post-OSCE. Additionally, when divided according to SP experience, that is novice versus experienced SP, most of the items on which there were changes were mutually exclusive between the groups. If these significant negative changes are due to the SPs becoming more educated consumers of medical care, this can be seen as a positive outcome. However, if the changes are due to variables particular to the third-year medical student OSCEs themselves, debriefing of the SPs following their participation in the OSCE may be warranted.

Scoring the objective structured clinical examination using a microcomputer.

The objective structured clinical examination (OSCE) is being used increasingly to assess students' clinical competence in a variety of controlled settings. The OSCE consists of multiple stations composed of a variety of clinically relevant problems (e.g. examining simulated patients, diagnosing X-rays, etc.) Generally, three types of performance data are collected: answers to multiple choice or true/false questions, written short answers, and performance check-lists completed by observers. In most OSCEs these student performance measures are scored by hand. This is time-consuming, increases the probability of mistakes and reduces the amount of data available for analysis. This paper describes a method of computer scoring OSCEs with over 100 students using statistical and test-scoring software regularly used for multiple choice examinations. During the examination, students, markers and raters code answers and performance data directly on optical mark-sheets which are read into the computer using an optical mark reader. The resultant computer data can be efficiently scored and rescored, grouped into different types of subscales, weighted to reflect questions' relative importance, and easily printed in a variety of report formats.

Is it worth it? A look at the costs and benefits of an OSCE for second-year medical students.

For the past two years, the Bowman Gray School of Medicine has used an Objective Structured Clinical Exam (OSCE) to measure the performance of 117 first- and second-year medical students at the end of introductory courses on differential and physical diagnosis. Given the surprisingly high costs of conducting the OSCE ($1300 for supplies and 527 person-hours of donated time), data about the format's perceived benefits were collected. All of the faculty involved in the examination who responded to a questionnaire (80%) reported that it was worth the time they had volunteered to evaluate students by observation and that the format should be used in the future. The majority of student examinees also reported that the OSCE format was appropriate for the course and should continue to be used.