A study of clinical concordance in pre and postgraduate students in Paedriatrics. Tal score

Abstract

Medical education programmes should result in the uniform development of clinical skills and criteria leading to a concordant assessment of clinical situations. 

Hypothesis: a scoring system (Tal) for assessing the clinical status for a group of signs on physical examination will produce a higher level of concordance between observers than each individual sign (a kappa index difference of > 0.20). 

Patients and Methods: sample size; according to previous data, with a standard error of the kappa index of 0.08, a difference within and between groups of 0.20, which was confirmed in a pilot study, estimated the sample size to be between 74 to 126 cases per group, with an alpha error of 5%. Observers were a random group of medical interns (n = 70) and medical doctors in the Paedriatric Specialty Programme (n = 30). The scoring system was assessed, considering the age of the patients, gender, nutritional status and diagnosis on admission. Statistics: Kappa indexes, c² in comparison of proportions. 

Results: 345 infants and children admitted with lower respiratory tract infections were examined, 167 by interns and 178 by medical doctors, both groups being similar at the initial examination. The Tal score in interns resulted in a kappa index of 0.515 and for individual signs from 0.080 to 0.379 and in doctors 0.230 and 0.163 to 0.277 respectively. A significant difference was observed for the Tal score in interns with a higher kappa index. In comparing concordance for each sign against the total score, there was only a significant change in the intern group, and for cyanosis and wheezing in 4 categories (p < 0.05). 

Conclusions: The observed concordance was rather weak for isolated signs and also for the complete scoring system of Tal. This gave a better concordance for individual signs only in interns and for cyanosis and wheezing. Teaching goals and methods to develop clinical skills should be reviewed.