Key Feature Questions - An Introduction

Key Feature Questions:

An Introduction

Dr. Chew Keng Sheng Universiti Sains Malaysia

What is a Key-Features Question? (KFQ)

•  KFQ are designed to specifically assess decision-making skills rather than simple recall of factual knowledge.

•  While knowledge is obviously a very important requisite for effective problem solving, the challenge posed by key features cases is the application of knowledge to the resolution of a problem

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Application of

knowledge

Elicit clinical clues

Formulate Dx

Order Ix

Acquire data for

monitoring

Evaluate severity/outcome

Select course of

action

Example

•  For example, KFQ should not assess examinees’ ability "to describe features of pulmonary embolism" (a knowledge issue); rather, they should assess their ability "to recognize pulmonary embolism in a specific patient" (a clinical reasoning issue) and "to prescribe appropriate emergency measures” (a clinical decision issue).


A general rule to keep in mind when developing key features cases is that if the question asked can be answered without reference to the attached

clinical scenario, then it is not a good question and is likely not measuring

clinical decision making.

Definition of Key-Feature

•  The term “key feature” was introduced by Bordage & Page (1987) and is defined as:

1. a critical or essential or key step(s) in the resolution of a problem,

2. a step(s) in which examinees are most likely to make errors in the resolution of the problem, or

3. a difficult or challenging aspect in the identification and management of the problem in practice.


Problem

A Key-Feature Step Resolution

of problem

Therapeutic Measure

VF Defibrillation Resolution

of VF

Clinical clues

Headache

Thunder-clap, Worst ever headache

Think of SAH

Investigative Procedure

Acute AMS in

a diabetic

Urgent blood sugar check Hypoglyce-

mia


All key-feature answers are correct answers but not all

correct answers are key-feature answers

Missing a key feature (critical step) may prove fatal to the case!


Acute SOB

following trauma Did not consider

Tension pneumothorax

Patient Died!!


Ask: “What are the critical, essential, or challenging elements in the resolution of this problem?”

“What are this problem’s key features that should be

assessed?”

Key Features are case-specific

•  Key features are often unique to different cases or presentations of a clinical problem, as they may vary relative to the clinical presentation of the problem and relative to other issues such as the patient's age and gender.

•  It is therefore unusual to have a “generic” set of key features for a specific clinical problem.


Key Features are case-specific

•  For example, the critical elements in the resolution of a diabetic problem as a life-threatening event are quite different from those of a diabetic problem presenting as an undifferentiated complaint in an adolescent


How an examiner sets a KFQ

•  First, define the key features of the case •  Each key feature has two/three basic elements: 1. a set of conditions: “Given a pregnant woman

experiencing third-trimester vaginal bleeding with no abdominal pain”;

2. a task (i.e., a clinical action or decision): “Consider placenta previa as a leading diagnosis”; and

3. some qualifiers (optional): “leading diagnosis.”


Example of a key-feature

•  Given that a pregnant women with third-trimester bleeding with no abdominal pain in Emergency department, a candidate at the level of undergraduate medical curriculum will

1. Consider placenta previa as a leading diagnosis 2. Avoid performing a pelvic examination 3. Avoid discharging home from emergency

department 4. Order pelvic ultrasound


The conditions

Given that <patient age group>

with <clinical situations>

in <sites of care>

Pregnant undifferentiated complaint

a prehospital setting

Neonate a single, typical problem

Green zone

Pediatric A multiple/multi-system problems

Yellow zone

General adult

A life-threatening event

Resus zone

elderly Emergency department

The tasks (optimally 2 – 3 per case)

Task (a critical step, decision, action that is a key feature

in the diagnosis/management specific to

this problem)

Domain tested

Ask/examine (History/PE) Consider (Diagnosis) Order (Investigation) Prescribe/administer/give

(Treatment)

Admit/discharge Disposition Avoid (taking precaution)

Setting up the case scenario

•  Once key features are defined, the case scenario is set:

•  “A 24-year-old G3P2 woman, 31/52 POA, comes to the emergency room at 8:00 pm complaining of bright red bleeding per vagina for the past 2 hrs. Three sanitary napkins that she used were completely soaked. No contractions or abdominal pain. The fetus is moving as usual. Her BP is 110/70 mm Hg, and pulse is 92/min. The examination of the abdomen reveals a uterine height of 31 cm with a soft and non-tender uterus. The fetus is in a breech position and has a heart rate of 150/min. No active bleeding has occurred since she arrived 25 minutes ago.”

Question Formats

•  Two response formats are recommended for clinical decision-making cases: –  short-answer "write-in" (WI) responses and –  "short-menu" (SM) responses.

•  In the WI format, examinees supply their responses.

•  In the SM format, examinees select their responses from prepared lists of options accompanying the question.

In SM Format

•  The number of options in these lists varies depending on what the question is testing.

•  In general there are typically 15-20 options. •  There should be ~ 2-3 times the total number of

choices in the list as there are number of correct responses

•  List of choices may contain correct non-scored responses (not a key-feature), incorrect distractors, and dangerous options if chosen (“killer responses”).

In SM Format

•  "Select up to x" is a suitable instruction for questions in which one or more answers are sought and for which the number of opportunities for examinees to provide these answers should be capped.

•  The number “x” considers the number of correct keyed responses sought, together with other factors such as responses that would be reasonable but are not keyed (e.g., general screening questions in a history-taking question).

In SM Format

•  Also, the number “x“ commonly provides a buffer for examinees to select some incorrect responses (e.g., if four correct responses are sought, five or six responses might be permitted).

Types of Response Limits in SM Format

Response limit Description List (select) only one. This type of limit is suitable for requesting a single

definitive answer, such as a leading diagnosis or a most important management step.

List (select) up to x This type of limit is suitable for questions in which one or more answers are sought and for which the number of opportunities for examinees to provide these answers should be capped (i.e., forcing the issue).

The “x” (number of allowable responses) takes into account the number of correct keyed responses sought, together with other factors such as responses that would be reasonable but not in the keyed responses as well as incorrect responses that might be appealing to weaker candidates


Types of Response Limits in SM Format

Response limit Description List (select) as many as are appropriate

This type of limit is used in situations where it is useful to determine how many actions an examinee might take, as in the case of limiting the investigation or treatment (i.e., not over investigating or treating).


References

•  Page G, Bordage G, Allen T. Developing Key-feature Problems And Examinations To Assess Clinical Decision-making Skills. Acad Med. 1995;70(3):194-201.

•  Medical Council Of Canada. Guidelines For The Development Of Key Feature Problems & Test Cases August 2012. Available At: http://mcc.ca/wp-content/uploads/cdm-guidelines.pdf Accessed 11 July 2014

Key Feature Questions - An Introduction

Health & Medicine

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