Relationship between type of surgical clerkship, order of completion, and achievement on patient management problems.

Complex cognitive skills, such as interpretation of information and problem solving, are essential for the practice of medicine. Patient management problems (PMPs) are used by both medical school faculty and certifying boards to measure higher-order cognitive skills. This study investigates two questions that relate to PMPs. Whether there is a difference among students in their achievement on PMPs that may be attributed to their clinical experience is examined. In addition, the effect of the order in which PMPs are taken is evaluated. For the purpose of this study, three PMPs were developed measuring three different areas of surgical problem solving. One hundred four third-year medical students who took their surgery clerkship during a 9-month period in 1982 were examined. Students were randomly assigned to one of three rotations for an 8-week period. At the end of the rotation, they each took three PMPs in random order. The multivariate analysis of variance procedure was used to examine the hypothesis of no relationship between clinical rotation and order of completion. The proficiency score for each PMP was considered the dependent variable. There was no difference in performance between groups rotating in different clinical surgical settings (multivariate F (6186) = 0.67; p = 0.67.) This suggests that generalization occurs with patient management and problem-solving skills. Statistically significant differences were found between groups on the basis of the order in which they took the PMPs (multivariate F (6186) = 4.07; p less than 0.001.) There are several plausible explanations for this finding. One explanation is that all three problems were difficult. As a result, students' perceptions about their performance on each problem may have influenced their performance on subsequent problems. Another explanation is that motivation to achieve may have diminished with time. These data suggest that there are basic management skills that may be taught in a variety of surgical experiences. Care must be taken in the use of the PMP as a tool for evaluation so that noneducational factors such as order do not play a role in the results.