Does Predominately Interviewing or Observing Required Patient Encounters Affect Year III Clinical Psychiatry Exam Results?

By Staci Becker, RN, MS; Robert J. Pary, MD Southern Illinois University School of Medicine

INTRODUCTIONIt is highly unusual for any medical school to provide uniform clinical experiences. Almost all clerkships emphasize learning by encountering patients on the wards and in the clinics. The number of patients that students encounter can vary tremendously. Another factor is student related. Some students are very active and will seek out these clinical experiences. Others are fairly passive and can pass a clerkship without pursuing many clinical encounters. The varying factors influencing the student-patient encounters prompted the LCME to take action.

The LCME specified in its ED-2 standard that clerkships must: 1) Identify the number and types of patients to be encountered2) Specify the degree of student involvement3) Monitor and verify that these encounters occur4) Adjust the clerkship for each student to ensure that all students have the desired clinical experience

To meet this standard, a Required Patient Encounter Card System (RPE) was implemented to track student experiences in a six week psychiatry clerkship. The card system was developed by the faculty at an annual educational retreat to bring the clerkship into compliance with the LCME’s educational standard, ED-2. Data has been collected on whether students meet the required patient encounters through interview, partial interview or observation.

OBJECTIVETo determine if students’ performance is significantly different on end of clerkship exams depending on whether they were primarily observers or interviewers during required patient encounter.

METHODOLOGYA Required Patient Encounter Card System (RPE) was implemented to track student experiences in a six week psychiatry clerkship. Data has been collected on whether students meet the required patient encounters through interview, partial interview or observation.

RESULTSRequired patient encounter data was analyzed using the following outcome measures: NBME subject exam scores, clinical exam patient findings, clinical exam patient H&P checklists and a patient satisfaction checklist. During the initial data analysis a significant inverse relationship between the subject examination and percent of encounters observed (r= -0.60; p=0.0002). This relationship was not sustained when the data from the second half of the year was added.

IMPLICATIONSDuring the initial analysis, the clerkship decided to set a maximum percentage of required patient encounters that are observed. The clerkship has set a requirement that no more than 7 of the 18 required encounters can be observed. Because the relationship was not sustained after analyzing the entire year, we have decided to collect an additional year of data.

Southern Illinois University School of MedicineDepartment of PsychiatryP.O. Box 19642Springfield, IL 62794-9642Telephone: (217) 545-7668Fax: (217) 545-2275E-mail: sbecker@siumed.edu rpary@siumed.edu

Shelf Test Performance by % Observed

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60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

% Observed

She

lf Te

st

Rotations 1-4 Rotations 5-8 Linear (Rotations 1-4) Linear (Rotations 5-8)

Symptoms In-pt % Out-pt % SP TotalPartial

Interview Interview Observe Total

ADHD 31 46.3% 34 50.7% 2 3.0% 67 11 16.4% 22 32.8% 34 50.7% 67

Anxiety 96 48.2% 92 46.2% 11 5.5% 199 42 21.1% 72 36.2% 85 42.7% 199

ID 82 61.7% 51 38.3% 0 0.0% 133 29 21.8% 51 38.3% 53 39.8% 133

Mal Adap 47 70.1% 18 26.9% 2 3.0% 67 17 25.4% 22 32.8% 28 41.8% 67

Mood 102 75.0% 27 19.9% 7 5.1% 136 16 11.9% 67 49.6% 52 38.5% 135

Psychotic 96 70.6% 39 28.7% 1 0.7% 136 33 24.3% 42 30.9% 61 44.9% 136

Sub Use 144 70.2% 45 22.0% 16 7.8% 205 23 11.2% 91 44.4% 91 44.4% 205

Suicidal 112 84.2% 10 7.5% 11 8.3% 133 20 15.0% 65 48.9% 48 36.1% 133

OVERALL 710 66.0% 316 29.4% 50 4.6% 1076 191 17.8% 432 40.2% 452 42.0% 1075

Rotations 1-4

%Interview %Partial %Observed

Shelf Test 0.46 0.22 -0.60

0.0072 0.2091 0.0002

Findings -0.01 0.08 -0.04

0.9427 0.6429 0.8464

Checklist -0.03 -0.15 0.12

0.8511 0.4131 0.5054

PatientSatisfaction

0.00 0.06 -0.03

0.9886 0.7526 0.8671

Rotations 5-8

%Interview %Partial %Observed

Shelf test -0.23 -0.01 0.27

0.1864 0.9589 0.1214

Findings -0.01 0.22 -0.15

0.9391 0.2093 0.3917

Checklist -0.51 0.50 0.20

0.0022 0.0028 0.2571

PatientSatisfaction

-0.14 -0.02 0.17

0.4461 0.9322 0.351