Department of Otorhinolaryngology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
Smart Reporting GmbH, Brienner Straße 13, 80333, Munich, Germany.
BMC Med Educ. 2019 Apr 11;19(1):102. doi: 10.1186/s12909-019-1538-6.
Reports of head and neck ultrasound examinations are frequently written by hand as free texts. This is a serious obstacle to the learning process of the modality due to a missing report structure and terminology. Therefore, there is a great inter-observer variability in overall report quality. Aim of the present study was to evaluate the impact of structured reporting on the learning process as indicated by the overall report quality of head and neck ultrasound examinations within medical school education.
Following an immersion course on head and neck ultrasound, previously documented images of three common pathologies were handed out to 58 medical students who asked to create both standard free text reports (FTR) and structured reports (SR). A template for structured reporting of head and neck ultrasound examinations was created using a web-based approach. FTRs and SRs were evaluated with regard to overall quality, completeness, required time to completion and readability by two independent raters (Paired Wilcoxon test, 95% CI). Ratings were assessed for inter-rater reliability (Fleiss' kappa). Additionally, a questionnaire was utilized to evaluate user satisfaction.
SRs received significantly better ratings in terms of report completeness (97.7% vs. 53.5%, p < 0.001) regarding all items. In addition, pathologies were described in more detail using SRs (70% vs. 51.1%, p < 0.001). Readability was significantly higher in all SRs when compared to FTRs (100% vs. 54.4%, p < 0.001). Mean time to complete was significantly lower (79.6 vs. 205.4 s, p < 0.001) and user satisfaction was significantly higher when using SRs (8.5 vs. 4.1, p < 0.001). Also, inter-rater reliability was very high (Fleiss' kappa 0.93).
SRs of head and neck ultrasound examinations provide more detailed information with a better readability in a time-saving manner within medical education. Also, medical students may benefit from SRs in their learning process due to the structured approach and standardized terminology.
头部和颈部超声检查报告通常以手写的自由文本形式书写。由于报告结构和术语缺失,这对该模式的学习过程造成了严重障碍。因此,整体报告质量的观察者间差异很大。本研究的目的是评估结构化报告对学习过程的影响,方法是评估医学院教育中头部和颈部超声检查的整体报告质量。
在头部和颈部超声沉浸课程之后,向 58 名医学生分发了三个常见病变的先前记录的图像,要求他们创建标准的自由文本报告(FTR)和结构化报告(SR)。使用基于网络的方法创建了头部和颈部超声检查的结构化报告模板。由两名独立评估者评估 FTR 和 SR 的整体质量、完整性、完成所需时间和可阅读性(配对 Wilcoxon 检验,95%CI)。评估了评分的观察者间可靠性(Fleiss'kappa)。此外,还使用问卷评估用户满意度。
SR 在所有项目中报告的完整性评分明显更高(97.7%比 53.5%,p<0.001)。此外,SR 更详细地描述了病变(70%比 51.1%,p<0.001)。与 FTR 相比,所有 SR 的可读性均显著更高(100%比 54.4%,p<0.001)。完成时间明显更短(79.6 比 205.4 秒,p<0.001),使用 SR 时用户满意度明显更高(8.5 比 4.1,p<0.001)。此外,观察者间可靠性非常高(Fleiss'kappa 0.93)。
在医学教育中,头部和颈部超声检查的 SR 以节省时间的方式提供更详细的信息,可读性更好。此外,由于结构化方法和标准化术语,医学生在学习过程中也可能受益于 SR。