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Table 1 Self-assessment question formats

From: Enhancing motivation with the “virtual” supervisory role: a randomized trial

Standard format Enhanced format
A 72 year old man presents for evaluation of chest pain. He has a history of 3-vessel CABG about 8 years ago, and he has been doing very well up until now. Over the past three months he has noted typical angina near the end of his daily two-mile walk. He also has moderate COPD, for which he uses albuterol with good effect, and hypertension. Medications include metoprolol, aspirin, lovastatin, and lisinopril. Exam reveals femoral bruits and decreased pedal pulses. You are supervising a medical student in continuity clinic. A 72 year old man presents for evaluation of chest pain. He has a history of 3-vessel CABG about 8 years ago, and he has been doing very well up until now. Over the past three months he has noted typical angina near the end of his daily two-mile walk. He also has moderate COPD, for which he uses albuterol with good effect, and hypertension. Medications include metoprolol, aspirin, lovastatin, and lisinopril. Exam reveals femoral bruits and decreased pedal pulses.
The most appropriate next step in management is: The medical student recommends an exercise ECG (treadmill exercise test). The most appropriate response is:
a) Exercise ECG (treadmill exercise test) a) That’s a good plan
b) Exercise sestamibi b) That’s not the best plan; we should order an exercise sestamibi because he has had CABG
c) Adenosine sestamibi c) That’s not the best plan; we should order an adenosine sestamibi because he has femoral bruits and diminished pedal pulses
d) Dobutamine echocardiogram d) That’s not the best plan; we should order a dobutamine echocardiogram because he has COPD and diminished pedal pulses
  1. Differences are in bold. Enhanced format placed the learner in a supervisory role. Single-best-answer multiple-choice questions were used in pairs matched for content. Feedback was identical for both formats.
  2. Feedback: In patients such as this, who have had coronary revascularization (either surgical or percutaneous), imaging studies are preferred over non-imaging studies. This patient does not appear to have significant limitation of physical activity, so exercise testing would be preferred. Exercise sestamibi would probably be the best choice given COPD, although an exercise echocardiogram would also be a reasonable option.