Is a web-based concordance test feasible to assess therapeutic decision-making skills in a French context?

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Practice points

Therapeutic decision-making is a major learning and assessment objective for the second part of the undergraduate curriculum in France. The selection process for students is based on a single assessment tool (patient management problem) and is controversial. A Web-based Concordance test is feasible in the French context with accurate reliability. Further research is required before including Concordance test as a part of the French National undergraduate Examination.

Table 1.  Examples of clinical vignettes and format of items used for the concordance test

Clinical vignette no. 1: You are called to the home of a 36-year-old plumber who presents with the first episode of acute lumbago on the right side, 24 h previously, following a period of heavy lifting.
If you were considering to prescribe	And then you discover	The relevance of this treatment becomes
Bi-Profenid® 150 mg per os 2/days	Previous medical history of chronic sinitus	−2 −1 0 +1 +2
Profenid® 100 mg, 1 injection IM	He had a urinary tract infection the previous week treated with Bactrim	−2 −1 0 +1 +2
Rest in bed for 13 days with Efferalgan Codeine, 2 per day	Temperature of 38°2	−2 −1 0 +1 +2
Clinical vignette no. 2: A 79 year old patient was hospitalized in the emergency department for pain resistant to treatment associated with a major alteration in his general status within a context of a developing 30-year history of sclerodermia.
If you were considering to prescribe	And then you find	The relevance of this treatment becomes
Morphine treatment	A very great reluctance of the patient to this type of treatment	−2 −1 0 +1 +2
No therapeutic treatment with a period of watchful waiting	Total refusal by the patient of any treatment whatsoever	−2 −1 0 +1 +2
Antidepressant treatment	There are no signs of depression	−2 −1 0 +1 +2
Clinical vignette no. 3: A 58-year-old man has high blood pressure (160/90 mmHg) treated to date with a Beta-blocker. This treatment should be discontinued due to an atrioventricular block dysfunction. An alternative antidepressant treatment is required.
If you were considering to prescribe	And then you find	The relevance of this treatment becomes
An enzyme conversion inhibitor	A creatinine clearance of 45 mL/mn	−2 −1 0 +1 +2
An central antihypertensive drug	A benign prostatic hyperplasia treated by an alpha-blocker	−2 −1 0 +1 +2
A calcium antagonist	Non-insulin-dependent diabetes mellitus	−2 −1 0 +1 +2

Notes: −2: contra-indicated; −1 not useful or even detrimental; 0: nor less no more useful; +1: useful; +2: necessary or absolutely necessary.

Figure 1. Illustration of the concordance test on line home page (URL: http://www.chu-rouen.fr/tcsecn).

Table 2.  Comparison of mean scores by groups according to level of clinical experience in therapeutic care

Group	Size	Mean score	SD	CI 95%
Students	113	64.06	7.62	62.64–65.48
Fourth-year students	16	58.93	11.42	52.84–65.02
Fifth and Sixth year students	97	64.91	6.50	63.60–66.22
Residents	34	67.65	6.57	65.36–69.94
Board certified practitioners	23	68.47	6.39	65.70–71.24

Notes: Statistical analysis were performed only on the 170 participants out of 251 who fully completed the test. SD: Standard deviation; CI: confidence interval.; One-way analysis of variance: p < 0.001. Bonferroni correction analysis: fourth-year students vs. residents, p < 0.001; fourth-year students vs. board certified practitioners, p = 0.001; entire group of students vs. residents, p = 0.038; entire group of students vs. board certified practitioners, p = 0.027. Other comparisons between groups were not significant.