How experienced community neurologists make diagnoses during clinical encounters

Teaching the Neurologic Examination: A Prospective Controlled Study to Compare a Blended Learning Approach With Face-to-Face Instruction

BACKGROUND AND OBJECTIVES

To compare a blended learning approach with traditional face-to-face instruction in terms of their individual effectiveness in imparting neurologic examination (NE) skills in medical students.

METHODS

We conducted a prospective controlled study of 4th-year medical students (n = 163) who were pseudorandomly distributed into 2 groups. Group A (n = 87) was subjected to a traditional teaching method comprising 2 face-to-face sessions. Group B (n = 76) underwent blended learning, which consisted of an individual preparation period using a course handbook and videoclips, plus a single face-to-face session. NE skill acquisition was assessed by an objective structured clinical examination (OSCE). Questionnaires were used for evaluation.

RESULTS

Comparison of mean OSCE scores in groups A vs B revealed that NE skill acquisition was better in group B (blended learning), with a moderate effect size, a smaller OSCE score variance, and fewer students performing poorly than in group A (face-to-face instruction). Student evaluation revealed that both teaching approaches were well accepted, but a higher level of satisfaction was associated with the blended learning approach. This method also provided more time for practice and feedback.

DISCUSSION

The blended learning approach is a highly efficacious and valued method for teaching NE skills. It offers instructors and faculty the advantage of successful skill acquisition in students despite the considerably reduced attendance time.

Ethnographic investigation of patient-provider communication among African American men newly diagnosed with prostate cancer: a study protocol

INTRODUCTION

In the USA, African American men bear a disproportionate burden of prostate cancer (PCa) compared with all other groups, having a higher incidence and mortality, poorer quality of life and higher dissatisfaction with care. They are also less likely to receive guideline-concordant treatment (eg, undertreatment of aggressive disease). Inadequate patient-provider communication contributes to suboptimal care, which can be exacerbated by patients' limited health literacy, providers' lack of communication skills and time constraints in low-resource, safety net settings. This study is designed to examine the communication experiences of African American patients with PCa as they undertake treatment decision-making.

METHODS AND ANALYSIS

Using an ethnographic approach, we will follow 25 African American men newly diagnosed with PCa at two public hospitals, from diagnosis through treatment decision. Data sources include: (1) audio-recorded clinic observations during urology, radiation oncology, medical oncology and primary care visits, (2) field notes from clinic observations, (3) patient surveys after clinic visits, (4) two in-depth patient interviews, (5) a provider survey, and (6) in-depth interviews with providers. We will explore patients' understanding of their diagnoses and treatment options, sources of support in decision-making, patient-provider communication and treatment decision-making processes. Audio-recorded observations and interviews will be transcribed verbatim. An iterative process of coding and team discussions will be used to thematically analyse patients' experiences and providers' perspectives, and to refine codes and identify key themes. Descriptive statistics will summarise survey data.

ETHICS AND DISSEMINATION

To our knowledge, this is the first study to examine in-depth patient-provider communication among African American patients with PCa. For a population as marginalised as African American men, an ethnographic approach allows for explication of complex sociocultural and contextual influences on healthcare processes and outcomes. Study findings will inform the development of interventions and initiatives that promote patient-centred communication, shared decision-making and guideline-concordant care. This study was approved by the University of California San Francisco and the Alameda Health System Institutional Review Boards.

A novel longitudinal framework aimed at improving the teaching of the neurologic examination

Objective

To develop an educational framework basis for improving the teaching of the neurologic examination (NE) by asking German neurologists to (1) identify the basic elements of the screening NE and (2) nominate the steps they would deem mandatory for medical students to master.

Methods

We conducted a questionnaire-based survey among neurologists working in a hospital or ambulatory setting in southwest Germany. To define the screening NE, neurologists were asked to list the NE components they normally use in clinical encounters with patients in whom neurologic findings are unlikely. Furthermore, they were asked to identify additional elements of the NE which they would consider mandatory for students to master.

Results

Our neurologists nominated a set of 23 elements as being essential for a screening NE. There was high consensus among the 2 groups, and the results were concordant with international data. Furthermore, nearly 60 additional maneuvers of the NE were deemed obligatory for students to master.

Conclusion

Our results reinforce the international consensus for screening NE components and confirm a large set of additional examination steps that medical students should master, thereby indicating the need for an educational NE teaching concept. To solve this educational challenge, we propose a longitudinal curriculum that incorporates the “core + clusters” framework, thus combining the screening NE (core) with hypothesis-driven sets of maneuvers (clusters). Based on our data, we provide an initial proposal for the core and neurologic diagnostic clusters which is applicable to both novice and advanced learners across the continuum of training.

Monitoring the Diagnostic Process on an Inpatient Neurology Service

The Institute of Medicine report Improving Diagnosis in Health Care called for tools to monitor physicians' diagnostic process. We addressed this need by developing a tool for clinicians to record and analyze their diagnostic process. The tool was a secure web application in which clinicians used a structured grading system to assess the relative impact of clinical, laboratory, and neuroimaging data for every new diagnosis. Four neurohospitalists used the tool for 6.5 months on a general neurology ward service at a single tertiary-level teaching hospital. Process measures of tool use included number of diagnoses entered, time spent on each data entry, and concordance of diagnoses compared to the medical record. We also aggregated the data across clinicians to examine the average process scores across common inpatient disorders. The 4 clinicians entered 254 new diagnoses that took approximately 3 minutes per patient. In 50 randomly chosen cases, the neurohospitalists' diagnoses entered into the tool agreed with 92% of diagnoses in the medical record, which was better than the agreement between billing code and medical record diagnoses (74%). The diagnostic process varied across disease categories, showing a spectrum of clinical-dominant (eg, headache), laboratory-dominant (eg, encephalitis), and neuroimaging-dominant (eg, stroke) disorders. This study demonstrated the feasibility of a clinician-driven diagnostic process monitoring system, along with preliminary characterization of the process for common disorders. The tracking of diagnostic process has the potential to promote reflection on clinical practice, deconstruct neurologists' clinical decision-making, and improve health-care safety.

How Patient Demographics, Imaging, and Beliefs Influence Tissue-Type Plasminogen Activator Use: A Survey of North American Neurologists

BACKGROUND AND PURPOSE

Understanding physician decision making is increasingly recognized as an important topic of study, especially in stroke care. We sought to characterize the process of acute stroke decision making among neurologists in the United States and Canada from clinical and epistemological perspectives.

METHODS

Using a factorial design online survey, respondents were presented with clinical data to mimic an acute stroke encounter. The history, examination, computed tomographic (CT) scan, CT angiogram, and CT perfusion were presented in sequence, and respondents rated their diagnostic confidence and likelihood of treatment with tissue-type plasminogen activator after each element. Patient age, race, sex, and CT perfusion imaging results were randomized, whereas the rest of the clinical presentation was held constant.

RESULTS

We collected 715 responses, of which 473 (66%) were complete. Diagnostic certainty and likelihood of treatment with tissue-type plasminogen activator rose incrementally as additional clinical data were provided. Diagnostic certainty and treatment likelihood were strongly influenced by the clinical history and the CT scan. Other factors such as physicians' personal beliefs or biases were not influential. Respondents' accuracy in interpreting CT angiographic and CT perfusion images was variable and generally low.

CONCLUSIONS

Diagnostic certainty and likelihood of treatment with tissue-type plasminogen activator increase with additional clinical data, with the history being the most important factor for diagnostic and treatment decisions. Respondents had difficulty in interpreting the results of CT perfusion scans although they had little impact on treatment decisions. We did not identify treatment bias based on patient age, race, or sex.