Noel G L, Herbers J E, Caplow M P, Cooper G S, Pangaro L N, Harvey J
Dartmouth Medical School, Hanover, NH.
Ann Intern Med. 1992 Nov 1;117(9):757-65. doi: 10.7326/0003-4819-117-9-757.
To determine the accuracy of faculty evaluations of residents' clinical skills and whether a structured form and instructional videotape improve accuracy.
Randomized, controlled trial.
Twelve university and community teaching hospitals.
A total of 203 faculty internists.
Participants watched a videotape of one of two residents performing new patient workups. Participants were assigned to one of three groups: They used either an open-ended evaluation form or a structured form that prompted detailed observations; some participants used the structured form after seeing a videotape showing good evaluation techniques.
Faculty observations of strengths and weaknesses in the residents' performance were scored. An accuracy score consisting of clinical skills of critical importance for a competent history and physical examination was calculated for each participant by raters blinded to the participants' hospital, training, subspecialty, and experience as observers.
When observations were not prompted, participants recorded only 30% of the residents' strengths and weaknesses; accuracy among participants using structured forms increased to 60% or greater. Faculty in university hospitals were more accurate than those in community hospitals, and general internists were more accurate than subspecialists; the structured form improved performance in all groups. However, participants disagreed markedly about the residents' overall clinical competence: Thirty-one percent assessed one resident's clinical skills as unsatisfactory or marginal, whereas 69% assessed them as satisfactory or superior; 48% assessed the other resident's clinical skills as unsatisfactory or marginal, whereas 52% assessed them as satisfactory or superior. Participants also disagreed about the residents' humanistic qualities. The instructional videotape did not improve accuracy.
A structured form improved the accuracy of observations of clinical skills, but faculty still disagreed in their assessments of clinical competence. If program directors are to certify residents' clinical competence, better and more standardized evaluation is needed.
确定教员对住院医师临床技能评估的准确性，以及结构化表格和教学录像带是否能提高准确性。
随机对照试验。
12所大学和社区教学医院。
共203名内科教员。
参与者观看两名住院医师之一进行新患者检查的录像带。参与者被分为三组：他们使用开放式评估表或提示详细观察的结构化表格；一些参与者在观看展示良好评估技巧的录像带后使用结构化表格。
对教员观察到的住院医师表现中的优点和缺点进行评分。由对参与者的医院、培训、亚专业和作为观察者的经验不知情的评分者为每位参与者计算一个由对合格病史和体格检查至关重要的临床技能组成的准确性分数。
当未给出提示时，参与者仅记录了住院医师30%的优点和缺点；使用结构化表格的参与者的准确性提高到60%或更高。大学医院的教员比社区医院的教员更准确，普通内科医生比专科医生更准确；结构化表格在所有组中都提高了表现。然而，参与者对住院医师总体临床能力的看法存在明显分歧：31%的人将一名住院医师的临床技能评估为不满意或勉强合格，而69%的人将其评估为满意或优秀；48%的人将另一名住院医师的临床技能评估为不满意或勉强合格，而52%的人将其评估为满意或优秀。参与者对住院医师的人文素质也存在分歧。教学录像带并未提高准确性。
结构化表格提高了临床技能观察的准确性，但教员在临床能力评估上仍存在分歧。如果项目主任要认证住院医师的临床能力，就需要更好、更标准化的评估。
