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Background In average-risk individuals aged 50 to 75 years, there is no difference in life-years gained when comparing colonoscopy every 10 years vs. annual fecal immunochemical testing (FIT) for colorectal cancer screening. Little is known about the preferences of patients when they have experienced both tests. Methods The study was conducted with 954 patients from the University of Iowa Hospital and Clinics during 2010 to 2011. Patients scheduled for a colonoscopy were asked to complete a FIT before the colonoscopy preparation. Following both tests, patients completed a questionnaire which was based on an analytic hierarchy process (AHP) decision-making model. Results In the AHP analysis, the test accuracy was given the highest priority (0.457), followed by complications (0.321), and test preparation (0.223). Patients preferred colonoscopy (0.599) compared with FIT (0.401) when considering accuracy; preferred FIT (0.589) compared with colonoscopy (0.411) when considering avoiding complications; and preferred FIT (0.650) compared with colonoscopy (0.350) when considering test preparation. The overall aggregated priorities were 0.517 for FIT, and 0.483 for colonoscopy, indicating patients slightly preferred FIT over colonoscopy. Patients’ preferences were significantly different before and after provision of detailed information on test features (p < 0.0001). Conclusions AHP analysis showed that patients slightly preferred FIT over colonoscopy. The information provided to patients strongly affected patient preference. Patients’ test preferences should be considered when ordering a colorectal cancer screening test.

Abstract Objectives: To characterise the information needs of family doctors by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases. Design: Observational study in which investigators visited doctors for two half days and collected their questions. Taxonomies were developed to characterise the clinical topic and generic type of information sought for each question. Setting: Eastern Iowa. Participants: Random sample of 103 family doctors. Main outcome measures: Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; information resources used. Results: Participants asked a total of 1101 questions. Questions about drug prescribing, obstetrics and gynaecology, and adult infectious disease were most common and comprised 36% of all questions. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?” Answers to most questions (702, 64%) were not immediately pursued, but, of those pursued, most (318, 80%) were answered Doctors spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources Only two questions led to a formal literature search. Conclusions: Family doctors in this study did not pursue answers to most of their questions. Questions about patient care can be organised into a limited number of generic types, which could help guide the efforts of knowledge base developers. Key messages Questions that doctors have about the care of their patients could help guide the content of medical information sources and medical training In this study of US family doctors, participants frequently had questions about patient care but did not pursue answers to most questions (64%) On average, participants spent less than 2 minutes seeking an answer to a question The most common resources used to answer questions included textbooks and colleagues; formal literature searches were rarely performed The most common generic questions were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?”

OBJECTIVE: To investigate whether patients are influenced by the order in which they learn the risks and benefits of a treatment and whether this effect is attenuated by a treatment's associated risk and/or benefit. DESIGN: Subjects were randomized to review 1 of 6 medical treatment information brochures. SETTING: Waiting rooms of primary care physicians at an academic health center. PARTICIPANTS: Six hundred eighty-five subjects, ages 18 to 70 years. INTERVENTION: Subjects reviewed 1 of 3 treatments for symptomatic carotid artery disease. The first (aspirin) was low-risk/low-benefit, the second (carotid endarterectomy surgery) was high-risk/high-benefit, and the third (extracranial-to-intracranial bypass surgery) was high-risk but of unknown benefit. Patients were also randomized to receive information about risk either before or after benefit. Patients were asked to rate the favorability of the treatment on a scale of 0 to 100 and whether they would consent. Finally, subjects rated how their decisions were influenced by the risk and benefit information. MAIN RESULTS: Subjects evaluating aspirin therapy were influenced by the order of the risk/benefit information. Those learning about risks after benefits had a greater drop in their favorability ratings than subjects learning about risks before benefits (-10.9 vs -5.2 on a 100-point scale; P=.02) and were less likely to consent (odds ratio, 2.27; P=.04). In contrast, subjects evaluating carotid endarterectomy and extracranial-to-intracranial bypass were not influenced by information order. When subjects were influenced by the order of information, they also reported that the treatment's risk had less influence on their decision making (P<.01). CONCLUSIONS: When patients evaluate low-risk medical interventions, they may form less favorable impressions of the treatment and be less likely to consent to the treatment when they learn about the risks after the benefits. Order effects were not observed with high-risk treatments regardless of potential benefits.[PUBLICATION ABSTRACT]

We examined how well primary-care physicians formulated their clinical referrals when asking for help with patient-related clinical problems using an email-based teleconsultation service. Over 100 family physicians made use of the service. The specialists were medical school faculty members. The service was initiated in May 1996 with 19 specialists and expanded to 34 specialties over the next five years. A total of 1618 patient-related clinical questions were analysed, the outcome for the analysis being whether specialists recommended a clinic consultation. Specialists recommended a clinic consultation in response to 10% of their clinical questions about patients. There was a strong association between how family physicians formulated their clinical questions and whether the specialist recommended a clinic consultation. When the family physicians specified a clinical task (P<0.001), intervention (P=0.004) and outcome (P<0.001) in their questions, specialists were less likely to recommend a clinic consultation. This influence was independent of the amount of clinical information included with the question (P>0.05). About 5% of the questions that included all three question components resulted in the recommendation for a clinic consultation, compared with nearly 30% of the questions containing none of these components. How family physicians formulate their clinical questions influences whether specialists request a clinic consultation.

The Objective Structured Clinical Examination (OSCE) is widely used to assess the clinical performance of medical students. However, concerns related to cost, availability, and validity, have led educators to investigate alternatives to the OSCE. Some alternatives involve assessing students while they provide care to patients - the mini-CEX (mini-Clinical Evaluation Exercise) and the Long Case are examples. We investigated the psychometrics of systematically observed clinical encounters (SOCEs), in which physicians are supplemented by lay trained observers, as a means of assessing the clinical performances of medical students. During the pediatrics clerkship at the University of Iowa, trained lay observers assessed the communication skills of third-year medical students using a communication checklist while the students interviewed and examined pediatric patients. Students then verbally presented their findings to faculty, who assessed students' clinical skills using a standardized form. The reliability of the combined communication and clinical skills scores was calculated using generalizability theory. Fifty-one medical students completed 199 observed patient encounters. The mean combined clinical and communication skills score (out of a maximum 45 points) was 40.8 (standard deviation 3.3). The calculated reliability of the SOCE scores, using generalizability theory, from 10 observed patient encounters was 0.81. Students reported receiving helpful feedback from faculty after 97% of their observed clinical encounters. The SOCE can reliably assess the clinical performances of third-year medical students on their pediatrics clerkship. The SOCE is an attractive addition to the other methods utilizing real patient encounters for assessing the skills of learners.

OBJECTIVE: To investigate whether patients are influenced by the order in which they learn the risks and benefits of a treatment and whether this effect is attenuated by a treatment's associated risk and/or benefit. DESIGN: Subjects were randomized to review 1 of 6 medical treatment information brochures. SETTING: Waiting rooms of primary care physicians at an academic health center. PARTICIPANTS: Six hundred eighty‐five subjects, ages 18 to 70 years. INTERVENTION: Subjects reviewed 1 of 3 treatments for symptomatic carotid artery disease. The first (aspirin) was low‐risk/low‐benefit, the second (carotid endarterectomy surgery) was high‐risk/high‐benefit, and the third (extracranial‐to‐intracranial bypass surgery) was high‐risk but of unknown benefit. Patients were also randomized to receive information about risk either before or after benefit. Patients were asked to rate the favorability of the treatment on a scale of 0 to 100 and whether they would consent. Finally, subjects rated how their decisions were influenced by the risk and benefit information. MAIN RESULTS: Subjects evaluating aspirin therapy were influenced by the order of the risk/benefit information. Those learning about risks after benefits had a greater drop in their favorability ratings than subjects learning about risks before benefits (−10.9 vs −5.2 on a 100‐point scale; P = .02) and were less likely to consent (odds ratio, 2.27; P = .04). In contrast, subjects evaluating carotid endarterectomy and extracranial‐to‐intracranial bypass were not influenced by information order. When subjects were influenced by the order of information, they also reported that the treatment's risk had less influence on their decision making (P < .01). CONCLUSIONS: When patients evaluate low‐risk medical interventions, they may form less favorable impressions of the treatment and be less likely to consent to the treatment when they learn about the risks after the benefits. Order effects were not observed with high‐risk treatments regardless of potential benefits.

Ambulatory blood pressure monitoring (ABPM) is an accurate method for evaluating hypertension, yet its use in clinical practice may be limited by availability, cost, and patient inconvenience. The objective of this study was to investigate the ability of a 6-hour ABPM window to predict blood pressure control, based on that of the full 24-hour ABPM session across several clinical indications in a cohort of 486 patients referred for ABPM. Sensitivities and specificities of the 6-hour systolic blood pressure mean to accurately classify patients as hypertensive were determined using a fixed reference point of 130 mmHg for the 24-hour mean. For four common indications in which ABPM was ordered, prediction tables were constructed varying the thresholds for the 6-hour mean to find the optimal value that best predicted the 24-hour hypertensive status as determined from the full 24-hour interval. Using a threshold of 137 mmHg for the indications of borderline hypertension, evaluation of current antihypertensive regimen and suspected white-coat hypertension, sensitivity and specificity ranged from 0.83–0.88 and 0.80–0.88, respectively, for the ability of 6-hour ABPM to correctly categorize hypertensive status. Using 133 mmHg as the threshold for treatment resistance resulted in a sensitivity and specificity of 0.93 and 0.83, respectively. We conclude that a shortened ABPM session of 6 hours can be used to accurately classify blood pressure as controlled or not, based on the results of a 24-hour session. The optimal 6-hour threshold for comparison depends upon indication for referral.

Objectives To characterize the information needs of family physicians by collecting the questions they asked about patient care during consultations and to classify these in ways that would be useful to developers of knowledge bases. Design An observational study in which investigators visited physicians for two half-days and collected their questions. Taxonomies were developed to characterize the clinical topic and generic type of information sought for each question. Setting Eastern Iowa. Participants Random sample of 103 family physicians. Main outcome measures Number of questions posed, pursued, and answered; topic and generic type of information sought for each question; time spent pursuing answers; and information resources used. Results Participants asked a total of 1,101 questions. Questions about drug prescribing, obstetrics and gynecology, and adult infectious disease were most common, comprising 36% of the total. The taxonomy of generic questions included 69 categories; the three most common types, comprising 24% of all questions, were “What is the cause of symptom X?” “What is the dose of drug X?” and “How should I manage disease or finding X?” Answers to most questions (n = 702 [64%]) were not immediately pursued, but of those pursued, most (n = 318 [80%]) were answered. Physicians spent an average of less than 2 minutes pursuing an answer, and they used readily available print and human resources. Only two questions led to a formal literature search. Conclusions Family physicians in this study did not pursue answers to most of their questions. Questions about patient care can be organized into a limited number of generic types, which could help guide the efforts of knowledge-base developers.

George R Bergus1–3, Jerold C Woodhead4, Clarence D Kreiter2,51Performance Based Assessment Program, Office of Student Affairs and Curriculum, 2Department of Family Medicine, 3Department of Psychiatry, 4Department of Pediatrics, 5Office of Consultation and Research in Medical Education, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, IA, USAIntroduction: The Objective Structured Clinical Examination (OSCE) is widely used to assess the clinical performance of medical students. However, concerns related to cost, availability, and validity, have led educators to investigate alternatives to the OSCE. Some alternatives involve assessing students while they provide care to patients – the mini-CEX (mini-Clinical Evaluation Exercise) and the Long Case are examples. We investigated the psychometrics of systematically observed clinical encounters (SOCEs), in which physicians are supplemented by lay trained observers, as a means of assessing the clinical performances of medical students.Methods: During the pediatrics clerkship at the University of Iowa, trained lay observers assessed the communication skills of third-year medical students using a communication checklist while the students interviewed and examined pediatric patients. Students then verbally presented their findings to faculty, who assessed students’ clinical skills using a standardized form. The reliability of the combined communication and clinical skills scores was calculated using generalizability theory.Results: Fifty-one medical students completed 199 observed patient encounters. The mean combined clinical and communication skills score (out of a maximum 45 points) was 40.8 (standard deviation 3.3). The calculated reliability of the SOCE scores, using generalizability theory, from 10 observed patient encounters was 0.81. Students reported receiving helpful feedback from faculty after 97% of their observed clinical encounters.Conclusion: The SOCE can reliably assess the clinical performances of third-year medical students on their pediatrics clerkship. The SOCE is an attractive addition to the other methods utilizing real patient encounters for assessing the skills of learners.Keywords: performance assessment, clinical skills, medical education

Ernst and Bergus discuss the advantages of ambulatory blood pressure monitoring (ABPM). The noninvasive 24-hour ABPM is a useful tool for clinicians in establishing accurate diagnoses and adjusting antihypertensive therapy. ABPM can provide useful information in the evaluation of borderline hypertension, antihypertensive efficacy, suspected white coat hypertension, and treatment resistance.