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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2823_Библиотеки_им_академика_М_И_Перельмана
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patient-centered care. The Assessment for Accountable Care
and Quality Supervision (AACQS) equation illustrates this
idea72 (Fig. 5.2). The AACQS equation states the product of a
learner’s competence (which is a function of their competence
in context) and the faculty’s competence (which is a function
of their competence in context) should result in safe, effective,
patient-centered care. In sum appropriate supervision
decisions require accurate knowledge of a learner’s skills.
This requires direct observation.
FIG. 5.2 Assessment for Accountable Care and Quality
Supervision equation.
Assessment Tools for Direct
Observation
Multiple assessment tools are available to assess learners
taking a history, doing a physical exam, and counseling
patients.
73–75
These assessment tools serve multiple purposes.
First, they can guide faculty in their observations of the
learner (what behaviors/skills faculty should attend to).
Second, they can be used to document the observation. Third,
they can be used to provide the learner with feedback.
High-quality direct observation requires using assessment
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tools with validity evidence. It is important to appreciate that
in WBA, the assessment instrument is the faculty, not the tool
(see Chapter 2). Two systematic reviews have summarized
the validity evidence for direct observation assessment
tools.
73,74
The mini clinical evaluation exercise (mini-CEX) is
one of the most commonly used WBA tools and has robust
validity evidence.
73,74,76
The mini-CEX was designed to
evaluate residents doing a focused history, physical
examination, or counseling on the inpatient wards, intensive
care units, outpatient clinics, and emergency department.77 It
also has been used with medical students and fellows.76 On
the original mini-CEX, faculty complete a 9-point rating scale
evaluating specific skills and overall competency and provide
immediate feedback to the learner (Fig. 5.3). Multiple
assessors making multiple observations over time improves
both the reliability and validity of the evaluations. Just four
mini-CEXs per resident can be acceptable for pass/fail
determinations or to determine whether a learner is
significantly struggling.
76,77
Use of the original mini-CEX has
declined substantially as multiple new iterations of the miniCEX have been developed with new scale descriptors and
anchors (see Figs. 5.3 and 5.4 and Chapter 4).
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FIG. 5.3 The mini-CEX.
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FIG. 5.4 The MiniCard. (From Donato AA, Park YS, George
DL, Schwartz A, Yudkowsky R. Validity and feasibility of the
minicard direct observation tool in 1 training program. J Grad
Med Educ . 2015 Jun;7(2):225-229. doi: 10.4300/JGME-D-14-
00532.1 .)
Assessment Tool Format
Direct observation assessment tools have different formats,
and formats have evolved over time. Some direct observation
assessment tools have global ratings; other assessment forms
are checklists. Forms also have different anchors (e.g.,
ordinal, normative, entrustment). In the following
subsections we describe some of these differences.
Global Ratings Versus Checklists
Some direct observation assessment tools ask evaluators to
select global ratings (i.e., giving a rating for history-taking
skills, physical exam skills, or overall clinical skills). The
mini-CEX is an example of a global rating scale. Other direct
observation tools are checklists (i.e., items are behaviors/skills
that comprise history taking or physical exam). The SEGUE
and Calgary-Cambridge instruments are examples of
checklists for medical interviewing.
78,79
The choice of
instruments depends primarily on the objectives of the
assessment.
Checklists can improve faculty observation quality by
increasing detection of specific errors.80 Checklists can help
faculty identify whether critical data-gathering actions are
completed and help them provide specific feedback to
learners. However, it is not feasible to develop highly
detailed checklists for every type of patient encounter. Some
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degree of faculty interpretation of behavior and skills is
required when working in clinical settings. Additionally, the
SP literature has raised concerns about the validity of highly
structured checklists
15–81
(see Chapter 6). However, the
differences between global ratings and checklist scores in
these studies were relatively small.82 Another downside of
using checklists with many items is that they may decrease
the number of relevant behaviors assessors identify and
decrease assessors’ capacity to differentiate between
performance levels.
83
,84
The impact is lower interrater
reliability. Long checklists also may increase the cognitive
load associated with the rating task.
85,86
Scale Anchors
Most direct observation assessment instruments use some
type of ordinal scale. Some numerical scales have adjectival
anchors such as unsatisfactory, satisfactory, and superior
(e.g., the original mini-CEX). Other tools have normative
anchors (below expectations, at expectations, exceeds
expectations). Some tools have behavioral anchors
(descriptions of the behaviors) associated with each rating
scale number. The Minicard is a direct observation tool with
behavioral anchors
87,88
(Fig. 5.4). Behavioral anchors
represent best practices that cue observers in each domain
and for each of the scoring levels. Behavioral anchors may
help assessors more accurately detect unsatisfactory
performance, identify specific behaviors, identify struggling
residents, and generate more action-oriented feedback.
87,88
Increasingly, direct observation assessment tools use
entrustment scales.
89–93
Entrustment scales can be
retrospective or prospective.
93,94
Retrospective entrustment
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scales ask the rater to indicate how much supervision a
learner needed (e.g., 1 = I had to do, 2 = I had to talk them
through, 3 = I had to prompt them from time to time, 4 = I
needed to be in the room just in case, 5 = I did not need to be
there). Prospective supervision scales ask the rater to indicate
how much supervision a learner is expected to need in the
future (e.g., 1 = Can be observer only, 2 = Direct supervision,
3 = Indirect supervision, 4 = Unsupervised practice, 5 = Able
to supervise others). Faculty often perceive entrustment
scales as more cognitively aligned with their experience and
supervision tasks.89 Early research suggested that using
entrustment anchors rather than conventional scoring
systems increased discrimination, improved reliability,
minimized assessor leniency, and better identified learners
performing below expectations.
89,92
Entrustment scales were
found to reduce the number of mini-CEXs needed from six to
three and the number of ratings for a surgical assessment
from 50 to 7 (to get a reliability coefficient of 0.7). In practical
terms, this means decreased assessor workload.
92
Entrustment anchors can make WBA ratings more concrete,
justifiable, and transparent as they convey learner progress
and can align with training outcomes to improve feedback.
91
However, more recently, educators have started to describe
problems with entrustment scales.
95–97
First, reliability does
not necessarily ultimately equate to validity as discussed in
Chapter 2. Entrustment decisions may differ depending on
whether assessors prioritize patient safety, efficiency, learner
welfare, or learner autonomy. Second, even if a learner is
deemed “entrustable,” ongoing observation is still needed for
feedback and coaching purposes to help learners gain
expertise over time.98 Finally, using entrustment scales does
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