Let's Test Your Clinical Competence

At the first of the year, many of us are evaluating the successes and failures of 1994 and planning and making this evaluation of ourselves and our practices, number of patient visits, patient referrals, net and gross income, etc. Perhaps the most important component of a successful practice, the doctor's clinical competence, rarely if ever gets evaluated. Although we all took a state and/or national board examination when we first obtained licensure, it is unlikely that many have had a general competency test since that time. So to help you make this most important evaluation of yourself, I have included a brief 10-question clinical competency test. The exam questions have been developed based on a few simple suppositions. We need to continue to learn new information about prevention, diagnosis, and treatment to stay informed and maintain a high level of clinical competence. To assimilate relevant new information, we must have skills that permit us to access the literature and have critical reading skills to understand what we have read. Most of the questions relate to primary care issues with emphasis on neuromusculoskeletal conditions with a couple of questions designed to test information retrieval and comprehension skills.

Competency Exam

1. Provocative injections of a noxious substance in the atlanto-axial joints of normal volunteer subjects provided the referred pain pattern of that joint. That pain pattern was: a. midline of the neck b. lateral neck c. jaw area below the ear d. all of the above (Spine 1994; 19(10): 1125-1131)

    

2. The RAND study: a. was a clinician trial that documented the value of spinal manipulation; b. demonstrated the value of chiropractic care for low back pain; c. reviewed previous research and concluded that spinal manipulation was valuable for treatment of some kinds of low back pain; d. all of the above.

    

3. Journals are the most important source of new information. Which of the following is a peer reviewed journal? a. gait and posture; b. Journal of Manipulation and Physiologic Therapeutics; c. Journal of Manual and Manipulative Therapy; d. all of the above.

    

4. A literature review published in the chiropractic literature concluded that treatment of lumbar disk herniation by spinal manipulation: a. is safe and effective; b. is contraindicated because of the excessive stress applied to the annular fibers of the disc; c. is only safe if the manipulation does not involve rotation (JMPT 1993; 16(2): 96-103).

    

5. The use of manual palpation to identify areas of tenderness prior to spinal manipulation is considered: a. as having poor interexaminer reliability (not reliable); b. as having fair interexaminer reliability (moderately reliable); c. as having good interexaminer reliability (very reliable) (Chiropractic Technique, 1994; 6(1): 4-8).

    

6. A 1993 review of literature related to neck and head injuries from motor vehicle accidents concluded that symptoms of insomnia, irritability, cognitive deficits and visual disturbances: a. arise primarily from organic lesions; b. arise primarily from psychological sources; c. arise primarily from monetary considerations (JNMS 1993; 1(4): 149-153).

    

7. This last year a new species of highly fatal hanatavirus was identified. Which of the following is not a feature of this deadly virus? a. symptoms include sore throat and coryza; b. symptoms include headache, cough, fever/chills, or diarrhea; c. cases to date have been primarily from the Southwest U.S. d. rodents are the primary reservoir. (JAOA 1993;93(12):1279-1285).

    

8. There is strong evidence that nutritional management of rheumatoid arthritis can effectively improve symptoms and reduce the need for drug therapy. Treatment involves all of the following except: a. supplementation with vitamin A and vitamin C; b. supplementation with bioflavonoids and niacinamide; c. supplementation with primrose oil, and vitamin E; d. reduction of dietary fats and avoid gluten, dairy, soy, eggs, and nightshades (Chiropractic Journal of Australia 1994; 24(3): 83-90).

    

9. Which of the following is not an online health related database? a. Exerpta Medica b. Chirolars c. Grateful Med d. Medline

    

10. When attempting to diagnose lumbar nerve root compression which has been demonstrated to be a more sensitive test? a. cervical flexion after hip flexion; b. maximum cervical flexion only; c. hip flexion after cervical flexion; d. maximum hip flexion only (Spine 1994; 19(21): 2421-2424).

You will find the answers at the end of the column. If you missed 0 to 2 questions, you have done an excellent job of keeping informed. If you missed 3 or 4, you need a little more work in 1995 to keep you from falling further behind. If you missed half or more, you may want to make a serious re-evaluation of your practice priorities.

Most of the self-evaluation questions as you no doubt have noted, were derived from the literature published in 1993 and 1994. These questions exemplify that you cannot rely on textbooks or other sources of information for what can only be found in the primary journal literature. It also gives you a feel for how much new information is produced each year that should be integrated in your daily practice in order to remain clinically competent. This is particularly true if you are functioning in the capacity of a primary care provider.

Most of us want to have a good, solid command of clinical information. We want to be able to develop good narratives, make proper referrals, intelligently rebut insurance denials, protect ourselves from malpractice, provide quality consulting, etc. However, a far more important issue is the ability to provide the best care possible to our patients. So, if you fared poorly on the mini competency exam above, take some of the following action steps in 1995:

1. Subscribe to three or four peer reviewed professional journals. There is much information in journals that will not appear in textbooks for another couple of years (see the journal list at the end of this column).

    

2. Subscribe to online literature indexes like Medline and Chirolars so that you can conveniently access the literature from your office.

    

3. Ask your state association or local chiropractic college to provide a course in information access and critical reading.

Finally, may 1995 be your most successful year in maintaining or regaining superior clinical competence.

ANSWERS TO EXAM: 1.(b), 2.(c), 3.(d), 4.(a), 5.(c), 6.(a), 7.(a), 8.(a), 9.(c), 10.(a)

Journal subscription phone numbers:

Chiropractic Technique 800-638-6423
Chiropractic Sports Medicine 800-638-6423
European Journal of Chiropractic (01865)791155
Journal of Chiropractic History 319-326-8450
JMPT 800-638-6423
Journal of Neuromusculoskeletal System 800-342-0454
Journal of Australian Chiropractors' Assoc. +61 69 213238
Journal of Canadian Chiropractic Assoc. 416-781-5656
Spine 800-638-3030
Topics in Clinical Chiropractic 800-638-8437

Ronald Rupert, MS, DC
Denton, Texas