Hodges B, Turnbull J, Cohen R, Bienenstock A, Norman G
Department of Psychiatry, University of Toronto, Canada.
Med Educ. 1996 Jan;30(1):38-43. doi: 10.1111/j.1365-2923.1996.tb00715.x.
In most objective structured clinical examinations (OSCEs), communication skills are assessed as an 'add-on' to history-taking stations, rather than in stations designed to assess communication skills in the broadest sense. This study investigated the feasibility of developing such stations. In part one, 60 clinical clerks and 36 residents were rated in four 10-min emotionally charged situations portrayed by standardized patients. Inter-rater reliability was demonstrated (r = 0.59-0.63) and a highly significant effect of educational level was found. Generalizability between communication stations was low (0.17-0.20). Several explanations for poor generalizability, including poor discrimination as a result of low score variance and the confounding effect of content knowledge, were addressed in part 2. Ninety-five final-year medical students participated in an OSCE in which six 10-min encounters examined the students' ability to manage difficult emotional situations such as fear, anxiety, mania, sadness, confusion and anger. Half the students encountered a patient with moderate emotional symptoms and half an extreme emotional state. For difficult stations, students' scores were lower and standard deviation higher, suggesting that manipulating difficulty increases score variance and potentially discrimination. However, a strong interaction was found between difficulty and station content, and communication scores were highly correlated with content. Scenarios which created major communication difficulties (such as mania) resulted in much larger differences in scores between the easy and difficult versions. Communication OSCE stations can be created with acceptable reliability including difficult cases which address communication skills beyond simple history taking. Nevertheless, a generalizable set of communication skills remains elusive.
在大多数客观结构化临床考试（OSCE）中，沟通技能是作为病史采集环节的“附加内容”进行评估的，而非在旨在从最广泛意义上评估沟通技能的环节中进行评估。本研究调查了开发此类环节的可行性。在第一部分中，60名临床实习医生和36名住院医生在由标准化病人描绘的四种10分钟情绪激动情境中接受评分。评定者间信度得到了验证（r = 0.59 - 0.63），并且发现了教育水平的高度显著影响。沟通环节之间的可推广性较低（0.17 - 0.20）。第二部分探讨了可推广性差的几种原因，包括由于分数差异小导致的区分度差以及内容知识的混杂效应。95名医学专业最后一年的学生参加了一次OSCE，其中六个10分钟的问诊考察了学生应对恐惧、焦虑、躁狂、悲伤、困惑和愤怒等困难情绪情境的能力。一半的学生遇到有中度情绪症状的患者，另一半遇到极端情绪状态的患者。对于难度较大的环节，学生的分数较低且标准差较高，这表明操纵难度会增加分数差异并可能提高区分度。然而，发现难度与环节内容之间存在强烈的交互作用，并且沟通分数与内容高度相关。造成重大沟通困难的情境（如躁狂）在简单版和困难版之间导致的分数差异要大得多。可以创建具有可接受信度的沟通OSCE环节，包括涉及简单病史采集之外沟通技能的困难病例。尽管如此，一套可推广的沟通技能仍然难以捉摸。
