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Variability and dimensionality of students’ and supervisors’ mini-CEX scores in undergraduate medical clerkships – a multilevel factor analysis
Full text linkAbstract Background The mini clinical evaluation exercise (mini-CEX)—a tool used to assess student-patient encounters—is increasingly being applied as a learning device to foster clinical competencies. Although the importance of eliciting self-assessment for learning is widely acknowledged, little is known about the validity of self-assessed mini-CEX scores. The aims of this study were (1) to explore the variability of medical students’ self-assessed mini-CEX scores, and to compare them with the scores obtained from their clinical supervisors, and (2) to ascertain whether learners’ self-assessed mini-CEX scores represent a global dimension of clinical competence or discrete clinical skills. Methods In year 4, medical students conducted one to three mini-CEX per clerkship in gynaecology, internal medicine, paediatrics, psychiatry and surgery. Students and clinical supervisors rated the students’ performance on a 10-point scale (1 = great need for improvement; 10 = little need for improvement) in the six domains history taking, physical examination, counselling, clinical judgement, organisation/efficiency and professionalism as well as in overall performance. Correlations between students’ self-ratings and ratings from clinical supervisors were calculated (Pearson’s correlation coefficient) based on averaged scores per domain and overall. To investigate the dimensionality of the mini-CEX domain scores, we performed factor analyses using linear mixed models that accounted for the multilevel structure of the data. Results A total of 1773 mini-CEX from 164 students were analysed. Mean scores for the six domains ranged from 7.5 to 8.3 (student ratings) and from 8.8 to 9.3 (supervisor ratings). Correlations between the ratings of students and supervisors for the different domains varied between r = 0.29 and 0.51 (all p < 0.0001). Mini-CEX domain scores revealed a single-factor solution for both students’ and supervisors’ ratings, with high loadings of all six domains between 0.58 and 0.83 (students) and 0.58 and 0.84 (supervisors). Conclusions These findings put a question mark on the validity of mini-CEX domain scores for formative purposes, as neither the scores obtained from students nor those obtained from clinical supervisors unravelled specific strengths and weaknesses of individual students’ clinical competence
A parametric analysis of ordinal quality-of-life data can lead to erroneous results
No full textObjective: Measurements from health-related quality-of-life (HRQoL) studies, although usually of an ordered categorical nature, are typically treated as continuous variables, allowing the calculation of mean values and the administration of parametric statistics, such as t-tests. We investigated whether parametric, compared to nonparametric, analyses of ordered categorical data may lead to different conclusions. Study Design and Setting: HRQoL data were obtained from patients with a diagnosis of asthma (n = 192) and chronic obstructive pulmonary disease (COPD; n = 88) at two time points. The impact of the group factor (asthma vs. COPD) and the time factor (t1 vs. t2) on HRQoL was analyzed with a metric approach (repeated measures ANOVA) and two ordinal approaches (each with a nonparametric repeated measures ANOVA). Results: Using the metric approach, a significant effect of "group" (P = 0.0061) and "time" (P = 0.0049) on HRQoL was found. The first ordinal approach (ranked total score) still showed a significant effect for "group" (P = 0.0033) with a worse HRQoL for patients suffering from COPD. In the second approach (ranks for each HRQoL item and summed ranks), there were no significant effects. Conclusion: Applying simple parametric methods to ordered categorical HRQoL scores led to different results from those obtained with nonparametric methods. In these cases, an ordinal approach will prevent inappropriate conclusions. (c) 2008 Elsevier Inc. All rights reserved
Role of the general practitioner in outpatient care for schizophrenic patients from the patients' perspective
No full textObjective To explore the view of schizophrenic patients regarding the role of general practitioners (GPs) in outpatient psychiatric care. Methods Semi-structured interviews with 20 schizophrenic patients were tape-recorded. Using the software Atlas.ti, the data were analysed according to the model of inductive category development (Mayring, 1995). Results Nearly all patients regarded the GPs as doctors "for the body" and - in contrast - the psychiatrists as doctors "for the soul". At the same time, an appointment with a GP was perceived as less embarrassing and stigmatising. Patients consulted their GP mainly because of somatic complaints or to receive follow-up prescriptions for their antipsychotic medication. They liked to get a "second opinion" regarding medical decisions by GPs. Some patients wished to have more consultation time with their GP to discuss psychological problems. Conclusions Schizophrenic patients appreciate the distinction, and the choice, between different medical specialties. Primary care offers services with an exceptionally low threshold for schizophrenic patients because consultations with a GP are to a lesser degree perceived as embarrassing or stigmatising
Association between the BclI glucocorticoid receptor polymorphism and smoking in a sample of patients with obstructive airway disease
No full textGlucocorticoids seem to mediate the effect of stimulant drugs such as nicotine. Several studies have pointed to an association between the BclI polymorphism in the glucocorticoid receptor gene and increased glucocorticoid effects. We analysed the association of smoking behaviour and the BclI polymorphism using a case-control design within the framework of a larger pharmacogenetic study. A total of 327 Caucasian patients with asthma or chronic obstructive pulmonary disease from 39 German general practices gave informed consent to take part in the study. They filled in questionnaires concerning their smoking behaviour and were genotyped for the BclI polymorphism. The genotype frequencies for non-smokers (n = 251; CC, 0.42; CG, 0.46; GG, 0.12) as well as for smokers (n = 76; CC, 0.29; CG, 0.55; GG, 0.16) were consistent with the Hardy-Weinberg equilibrium. The proportion of smokers was significantly lower among carriers of the CC-genotype (22/127 = 17%) compared with carriers of the G-allele (54/200 = 27%; chi(2) = 4.08; P = 0.04). Within the group of smokers, the proportion of heavy smokers (> 19 cigarettes/day; median) was reduced in C-homozygous patients when compared with carriers of the G-allele (7/22 = 32% versus 31/54 = 57%; chi(2) = 4.09; P = 0.04). Stepwise logistic regression analysis also pointed to an association between the CC-genotype and a reduced probability of being a smoker (odds ratio = 0.55; 95% confidence interval = 0.30-1.00; P = 0.05) controlling for other predictors. In summary, this study provides evidence that the BclI polymorphism might play a role in the maintenance and severity of nicotine dependence
Arbeitsplatz-basiertes Assessment im Medizinstudium: Ist eine Multilevel-Analyse sinnvoll?
No full textHintergrund. Einschätzungen der praktisch-klinischen Fähigkeiten von Studierenden (z. B.
Anamnese- u. Gesprächsfähigkeiten) finden an vielen Universitäten mittlerweile regelmäßig
statt: zur Messung des individuellen Lernerfolgs, aber auch zur Feststellung von Unterschieden
in der didaktischen Qualität von Lehrenden. Studierende werden durch eine oder
mehrere Personen in mehreren Kliniken/Instituten bzw. medizinischen Fächern zumeist
mehrfach bewertet. Einfache Auswertungen dieses Materials können zu Fehlurteilen führen,
da die Einschätzungen nicht unabhängig voneinander sind. Das ist als generelles Phänomen
unter dem Begriff Mehrebenen- oder Multilevel-Struktur bekannt, wird aber eher
selten berücksichtigt – u. a. weil entspr. Statistik-Programme für dieses Problem nicht ganz
einfach in der Anwendung sind.
Ziel. Anhand eines umfangreichen Datensatzes von Mehrfach-Bewertungen von 165 Medizinstudierenden
in verschiedenen Kliniken soll gezeigt werden, wie mit dem Programm
proc mixed von SAS der Multilevel-Charakter der Daten berücksichtigt werden kann.
Spezifische Fragestellung und Methode. Es sollte untersucht werden, wovon die Fremdeinschätzungen
von Medizinstudierenden im Rahmen sog. Mini Clinical Evaluation Exercises
(Mini-CEX) mitbeeinflusst sind. Dafür wurden in der Prozedur proc mixed sog. Fixed
effects und random effects eingeführt („gemischtes Modell“), um ihre Wirkung auf die Ergebnisse
zu zeigen.
Ergebnisse. Im gemischten Modell waren mehrere Variablen signifikante Prädiktoren für
die Gesamteinschätzung der studentischen Leistungen. Zum Beispiel gaben Assistenzärzte
deutlich bessere Einschätzungen für die Studierenden – im Vergleich zu Ober- und Chefärzten.
Zurückhaltender in den Einschätzungen, also kritischer gegenüber den Studierenden
waren die Ergebnisse aus kleineren Kliniken und bei geringerer Komplexität der zu
bewertenden Sachverhalte. Im linearen Modell wären dagegen weitere Faktoren – fälschlicherweise
– als signifikant markiert worden
- …
