EVALUATING PROBLEM-SOLVING BASED ON THE USE OF HISTORY FINDINGS IN A STANDARDIZED-PATIENT EXAMINATION

Purpose. To evaluate a novel item format for assessing clinical proble m solving in a standardized-patient examination (SPE). Method. In 1992 -93 a key-findings item format was included in two versions of three s tations in an SPE (given in the style of an objective structured clini cal examination) that was taken by 198 third-year students at the end of their three-month internal medicine clerkship at the University of Texas Medical Branch at Galveston. Each of the stations involved an ex tended matching question that listed ten to 12 findings. The students were told to select as many or as few findings as they wished that wer e key in leading them to their diagnosis of the standardized patient's (SP's) problem. The findings fell into three categories: (1) key to t he diagnosis, (2) provided by the SP but not key to the diagnosis, and (3) not provided by the SP. Results. A total of 169 students (85%) id entified at least one of the findings determined to be key in each of the stations. Correctly identifying key findings was related to correc tly diagnosing the SP's problem. A total of 145 students (73%) indicat ed at lease one finding across the three cases as key to their diagnos is but not given by the SP. Selecting nonexistent findings as key to d iagnosis was not found to be related to performance on the SPE. It was hypothesized that once a diagnosis was made, the students had difficu lty differentiating key features of their cognitive model of illness. Conclusion. The students were generally able to obtain and recognize a t least some of the key information they needed to formulate appropria te differential diagnoses, and the ability to identify key findings wa s shown to be related to identifying the most appropriate diagnosis. T he key-findings item format has potential both in assessment and for g aining a better understanding of the clinical problem-solving process.