Department of Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, Illinois 50612, USA.
Med Educ. 2009 Aug;43(8):729-40. doi: 10.1111/j.1365-2923.2009.03379.x.
Diagnostic accuracy is maximised by having clinical signs and diagnostic hypotheses in mind during the physical examination (PE). This diagnostic reasoning approach contrasts with the rote, hypothesis-free screening PE learned by many medical students. A hypothesis-driven PE (HDPE) learning and assessment procedure was developed to provide targeted practice and assessment in anticipating, eliciting and interpreting critical aspects of the PE in the context of diagnostic challenges.
This study was designed to obtain initial content validity evidence, performance and reliability estimates, and impact data for the HDPE procedure.
Nineteen clinical scenarios were developed, covering 160 PE manoeuvres. A total of 66 Year 3 medical students prepared for and encountered three clinical scenarios during required formative assessments. For each case, students listed anticipated positive PE findings for two plausible diagnoses before examining the patient; examined a standardised patient (SP) simulating one of the diagnoses; received immediate feedback from the SP, and documented their findings and working diagnosis. The same students later encountered some of the scenarios during their Year 4 clinical skills examination.
On average, Year 3 students anticipated 65% of the positive findings, correctly performed 88% of the PE manoeuvres and documented 61% of the findings. Year 4 students anticipated and elicited fewer findings overall, but achieved proportionally more discriminating findings, thereby more efficiently achieving a diagnostic accuracy equivalent to that of students in Year 3. Year 4 students performed better on cases on which they had received feedback as Year 3 students. Twelve cases would provide a reliability of 0.80, based on discriminating checklist items only.
The HDPE provided medical students with a thoughtful, deliberate approach to learning and assessing PE skills in a valid and reliable manner.
在体格检查（PE）期间，通过牢记临床体征和诊断假设，可以最大程度地提高诊断准确性。这种诊断推理方法与许多医学生学习的机械、无假设的筛查 PE 形成对比。已经开发出一种基于假设的 PE（HDPE）学习和评估程序，以在诊断挑战的背景下，针对预测、引出和解释 PE 的关键方面提供有针对性的实践和评估。
本研究旨在获得 HDPE 程序的初步内容有效性证据、绩效和可靠性估计以及影响数据。
开发了 19 个临床场景，涵盖 160 个 PE 操作。共有 66 名三年级医学生在所需的形成性评估中准备并遇到了三个临床场景。对于每个病例，学生在检查患者之前列出了两个可能诊断的预期阳性 PE 发现；检查了模拟其中一种诊断的标准化患者（SP）；从 SP 立即获得反馈，并记录他们的发现和工作诊断。同一批学生后来在他们的第四年临床技能考试中遇到了其中一些场景。
平均而言，三年级学生预测了 65%的阳性发现，正确执行了 88%的 PE 操作，并记录了 61%的发现。四年级学生总体上预测和引出的发现较少，但比例上更具鉴别力，从而更有效地达到与三年级学生相当的诊断准确性。在作为三年级学生接受反馈的情况下，四年级学生在案例上表现更好。仅基于鉴别清单项目，12 个案例将提供 0.80 的可靠性。
HDPE 为医学生提供了一种深思熟虑、深思熟虑的方法，以有效和可靠的方式学习和评估 PE 技能。
