Family Practice Vol. 18, No. 6, 590-591
© Oxford University Press 2001
Original Paper |
Mean clinical challenge rate and level of recognition of depression remain unchanged after two years of vocational training
Department of General Practice, vrije Universiteit, Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
van Marwijk H, Gercama A, Adèr H and de Haan M. Mean clinical challenge rate and level of recognition of depression remain unchanged after two years of vocational training. Family Practice 2001; 18: 590–591.
Received 23 August 2000; Revised 4 April 2001; Accepted 9 July 2001.
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Abstract |
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Objectives. Our aim was to evaluate whether trainees encounter more difficult clinical situations (clinical challenge rate) and more patients with signs of depression in the last year of their training (T1) than in the first year (T0), and whether depression is recognized by trainees more frequently at T1 than at T0.
Methods. An evaluation was undertaken of videotapes made by a random sample of 48 vocational trainees in general practice. Experienced staff members (GPs) assessed the clinical challenge rate of consultations at the two time points with the reliable and valid Amsterdam Clinical Challenge Scale (ACCS). They also rated the presence of signs of depression in the consultations (yes/no) and whether these were recognized by the trainee (yes/no).
Results. Baseline and follow-up measurements (T0 and T1) were available for 45 trainees, from the original cohort of 48 at T0, and for 527 consultations. Both at T0 and at T1, the mean ACCS score was 2.3 (T0 SD = 0.95; n = 269) (T1 SD = 0.92; n = 258). For each trainee, the mean difference in ACCS score between T0 and T1 was 0.01 [95% confidence interval (CI) –0.15 to 0.17]. According to staff-assessments, 66 patients had signs of depression (34 at T0 and 32 at T1). Trainees recognized depression in 12 consultations (12/34 = 35%) at T0 and in 11 consultations (11/32 = 34%) at T1 (relative risk 1.0; 95% CI 0.4–2.9).
Conclusion. A focus on the challenge level of consultations, an individualized, integrated approach and the introduction of a new final consultation skills examination may be the way forward.
Keywords. Clinical challenge rate, depression, general practice, postgraduate training.
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Introduction |
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Vocational trainees for general practice have to learn to detect and manage problems with varying degrees of clinical difficulty to prepare themselves for the wide variety of unselected problems they will face subsequently in everyday practice. The usual mix of problems ranges from plugged ears to depressed patients with neck-aches.
Within the 3-year Dutch curriculum for general practice, effective since September 1994, an important aim is a gradually increasing degree of clinical challenge: more difficult problems at the end.1 Patients with mental problems such as depression are among the more difficult encounters. The aim was to evaluate whether trainees had managed to encounter more difficult clinical situations (and more patients with signs of depression) in the last phase of their training. An additional question was whether trainees detected signs of depression more frequently.
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Methods |
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A random sample of 48 trainees in the third month of their training (T0) videotaped 20 consultations with the consent of the patients, as part of a Dutch national project.2 T1 was 27 months later. The consultations were placed in random order on the videotapes, and were assessed anonymously and blind as to whether a consultation took place at T0 or T1. Reliability and validity of the Amsterdam Clinical Challenge Scale (ACCS) have been convincingly shown.3,4 Fourteen staff members (GPs) were instructed according to the manual, and assessed video-recorded consultations with the ACCS. They also rated the presence of signs of depression in the consultation (yes/no) and whether these were recognized by the trainee (yes/no).
Analysis
Means, differences in means, percentages and 95% confidence intervals (CIs) are reported. A multilevel analysis was performed (videotape as level 1; GP-assessor as level 2) with ACCS score as the dependent variable and a logistic multilevel analysis with the depression variable (yes/no) as the dependent. A t-test on mean ACCS score for both time points was performed. To evaluate the trainees's recognition rate of depression, a relative risk approach was chosen.
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Results |
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Measurements at both T0 and T1 were available for 45 trainees from the original cohort of 48 at T0. The 45 trainees had made 592 videotapes, 527 of which were available for analysis.2 Sixty-five consultations were inaudible, poorly recorded or otherwise inadequate. Of the 20 videotapes made by these 45 trainees, six videotapes per trainee were selected randomly at T0 (mean; SD 3.8; range 1–17) and 5.7 tapes at T1 (SD 3.2; range 1–13). The sample of videotapes consisted of 269 tapes at T0 and 258 tapes at T1. These were assessed by 14 experienced GP-teachers (practice years 14.7; SD 7.9; range 5–26 years; 11 men and three women).
Table 1
presents the ACCS scores (1–5; from 1 = easy to 5 = difficult). The mean ACCS scores at T0 and T1 were both 2.3 (SD 0.95, and 0.92, respectively). For each trainee, the mean difference in ACCS score between T0 and T1 was 0.01 (95% CI –0.15 to 0.17). As only three consultations had an ACCS score of five, the ACCS was actually a 4-point scale. Ninety percent of the variance in ACCS assessment was attributable to variance between trainees, and 10% to variance between GP-assessors, which indicates a reasonable inter-rater agreement. The assessors's gender and depression detection level influenced their ACCS scores of consultations. In 66 of the 527 available consultations, there were signs of depression according to assessors, 34 at T0 and 32 at T1. The trainees picked up depression signs in 12 consultations (35%) at T0, and in 11 consultations (34%) at T1 [relative risk (RR) 1.0; 95% CI 0.4–2.9]. Of these 66 consultations, 50 had an ACCS score of at least 3 (moderate) or higher. Consultations with patients with signs of depression scored 1.0 ACCS point higher on average (95% CI 0.8–1.2) than consultations without signs of depression, and were thus considered more difficult. The number of practice years of the assessor and the ACCS level of the video influenced the recognition level of depression.
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Discussion |
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The results were surprising, as an increase in ACCS scores and rate of depression over the two time points was expected. Trainees are required to see more complex (e.g. depressed) patients in their third year, to practise and integrate various skills. The lack of improvement in depression recognition skills after 3 years was less of a surprise. A different analysis of the same videotapes also indicated a lack of progress in the equivalent but somewhat broader concept of ‘general consultation skills’.2 However, sufficient improvement was demonstrated with respect to trainees' overall general practice knowledge, skills knowledge and medical technical skills.2 While the skills that show improvement are tested regularly, general consultation skills currently are not tested. Therefore, an objective consultation skills examination (including, for instance, a depressed patient) seems the way forward. Methodologically, a design with the same patients at the two time points would have excluded some variation due to patients. However, such a design is not possible in practice. We currently are exploring whether the ACCS can help trainees to focus more on clinical difficulty.
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References |
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1 Springer MP. Basic Job Description for the General Practitioner [available in English]. Utrecht: Landelijke Huisartsen Vereniging, 1983.
2 Tan LHC, Kramer AWM, Jansen JJM, Düsman H. Nationwide evaluation of GP vocational training in the Netherlands: the development of trainees's competencies [in Dutch, with English summary]. Huisarts Wet 2000; 43: 415–419.
3 Gercama AJ, de Haan M, van der Vleuten CPM. Reliability of the Amsterdam Clinical Challenge Scale (ACCS): a new instrument to assess the level of difficulty of patient cases in medical education. Med Educ 2000; 34: 519–524.[Medline]
4 Gercama AJ. Categorisation of consultations by level of difficulty: the Amsterdam Clinical Challenge Scale [in Dutch]. Bull Med Onderwijs 1992; 11: 14–21.
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