Maintaining and Enhancing Key Decision-Making Skills from Graduation into Practice: An Exploratory Study

Summary

Key feature-based exams focus on clinicians’ ability to make decisions about critical steps in the identification and management of clinical problems. The purpose of this study was to explore the extent to which these key decisions are maintained or enhanced from graduation into practice. A booklet containing 18 clinical problems testing 44 key features (KFs) was administered to 98 graduating students and 21 volunteer general practitioners who were three to five years into practice. Students and experienced physicians had similar mean scores (t-tests, p>.05) for 36 of the 44 KFs (82%). Physicians scored significantly higher (+25%, p<.05) on three KFs, two related to treatment and one to investigation. The physicians scored significantly lower (-28.4%, p<.05) on two history related KFs, two physical exam KFs, and one investigation KF. The results from this exploratory study suggest that experience did not have a big effect on key decision-making skills, with experienced physicians showing slightly enhanced management decisions and some lessened skills for data acquisition. A content analysis of these latter items revealed that the experienced physicians were not failing to meet the scoring criteria by taking shortcuts (e.g., only supplying 2 out of 3 keyed responses). Instead, they were considering different leading diagnoses (the “wrong ballpark”). For example, they did not order a lower GI investigation in an elderly person, thus failing to consider GI bleeding as a possible etiology, a condition that is imminently treatable. One possible explanation for the shrinking differential diagnosis may be the low incidence of certain diagnoses in practice; out of sight, out of mind.