Vol.3, No.10, 626-630 (2011)
doi:10.4236/health.2011.310106
C
opyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Health
Effect of an educative intervention on the clinical ability
of physicians in the risk factor identification of
metabolic syndrome
Carlos E. Cabrera-Pi varal1,2*, Bella ney G. Hobert-Cepeda1,3, Astrid L. Berdugo-Rodriguez3
1Unidad de Investigación en Epidemiología Clínica, Hospital de Especialidades, Centro Médico Nacional de Occidente, Instituto
Mexicano del Seguro Social, Guadalajara, México; *Corresponding Author:
2Centro de Investigación en Salud, Departamento de Ciencias Sociales, Departamento de Salud Pública; Centro Universitario de
Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, México;
3Universidad Autónoma de Guadalajara, Guadalajara, México.
Received 14 May 2011; revised 27 June; accepted 29 August 2011.
ABSTRACT
Aim: To measure the effect of an educative in-
tervention on the clinical ability of family physi-
cians of two First Contact Units, (UMF, IMSS)
from the metropolitan area of Guadalajara, in the
Risk Factor Identification of met abolic syndrome.
Methodology: A quasi-experimental study was
carried out with a control group using basal and
final measurements. The educative intervention
of the experimental group included one in-the-
classroom work and another at the consulting
room. Instrument was validated by a panel of
experts and consisted of 40 questions of five
cases presenting problems, reaching a reliabil-
ity index of 0.84. Results: There was no signifi-
cant differen ce at base m easu remen t am ong the
different levels of clinical ability among groups
(p = 0.82). At the end of the follow-up, a signifi-
cant increase in the experimental group (29 with
20 - 23 vs. 29 with 24 - 33 in the control group)
was observed. Conclusions: The advantage ob-
served at the diff ere nt le vels of the experimental
group reflects the impact of the alternative edu-
cative program which needs to be a program-
matic guide for future educative interventions
for health workers seeking to transform their
own clinical practice.
Keywords: Clinical Ability; Metabolic Syndrome;
Educative Intervention
1. INTRODUCTION
In Mexico, the prevalence of MS among the adult
population is higher than in Caucasian populations [1,2];
more than 6 million Mexicans are affected if the criteria
of the World Health Organization (WHO) is applied, and
more than 14 million if the criteria of the third adult
treatment panel (ATP III) of The National Cholesterol
Education Program (NCEP) is applied [3].
On the other hand, it has been shown that weight loss
is the only intervention that improves all risk factors
observed in MS patients. This is a clear sign of the ne-
cessity to implement preventative measures as well as
prompt attention to MS.
This syndrome requires prompt identification and
clinical management by the first contact physician. This
management ability permits the physician to recognize
risk factors, which in the end would be reflected by a
reduced risk for diabetes mellitus type 2 and cardiovas-
cular disease for patients.
The education of health personal on Risk Factors
Identification (RFI) requires an adequate means to assess
the scope and limitations of clinical ability achieved
during formation and its own professional practice. As-
sessment of physicians has traditionally been made in a
stereotyped manner, memory-oriented, and much of the
time centered on questions unrelated to clinical practice.
It is occasionally carried out with clinical cases almost
always obtained from a book and with multiple choice
answers [11].
Being able to assess the ability and competence of phy-
sicians in solving clinical problems that they may face has
always been a major concern for educators [7-9].
Clinical competence and ability is defined as the per-
formance of the physician in problematic clinical situa-
tions. A competent medical practitioner is one who pos-
sesses the necessary skills, knowledge and attitudes, and
able to synthesize these attributes by a complex set of
behaviors to deliver high-quality medical care [10].
The aim of the study was to measure the effect of an
educative intervention on the clinical ability of family

C. E. Cabrera-Pivaral et al. / Health 3 (2011) 626-630
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
627627
physicians (FP) of two First Contact Units, (FCU) at the
Instituto Mexicano del Seguro Social (IMSS), in the RFI
of MS [12].
2. MATERIALS AND METHODOLOGY
This is a quasi-experimental study with a control
group using base and final measurements. It was carried
out on FP of First Contact Unit (FCU) A and B at the
Instituto Mexicano del Seguro Social, Jalisco Delegation,
during the period from January to October 2008.
2.1. Sample
We performed a non-aleatory selection of two FCUs
from the 23 units in the area of Guadalajara. Among
other characteristics of these units are the following:
both units provided patients diagnosed with MS, and are
similar in terms of the number of consulting and support
services (laboratory, X-ray, etc.). All family physicians
at the FCU who met the criteria were invited to partici-
pate in the educative intervention.
2.2. Variables
Independent: Participative educative intervention in
the experimental group. Intervener: Time of professional
activity as family medicine specialist. Dependents:
Clinical ability. Risk Factor Identification is defined as
the competency which enables the family physician, in
the face of a problematic case, to confront difficult situa-
tions of clinical experience of variable complexity.
2.3. Stud y Stages
1) Development and validation of an instrument to
assess the clinical ability of family physicians in the
management of the patient with MS. An instrument to
explore the grade of competence and clinical ability was
constructed; it measures the family physician’s ability to
carry out interpretations, judgments and proposals in the
face of four real clinical cases theoretically made up of
patients. The instrument was subjected to a panel of 5
experts, that is, 3 endocrinology specialists and 2 inter-
nal medicine specialists dedicated to clinical practice for
a minimum of 2 years, who conferred to the instrument a
validity of concept, contents and criteria.
The instrument is made up of 40 questions spread
over indicator: identification of risk factors. Taking into
account the experts’ observations, 20 questions with true
correct answers and 20 with false correct answers, a
glossary of terms was created with the precise meanings
of the terms utilized in the questions. The instrument
reliability had a Kuder-Richardson coefficient of 0.84.
[13,14]
2) Development and validation of contents, criteria
and management standards for the MS patient. A study
guideline that includes explicit criteria and standards in
algorithmic form was created for diagnosis and treat-
ment. Construction of the algorithm was carried out ba-
sed on available scientific literature and was validated
through a consensus of experts. [14-16]
3) Implementation of experimental educative strategy.
The range of the educative strategy is based on the par-
ticipative focus of students through communication; uti-
lizing dialog, exchange of ideas, and sharing mutual ac-
tions in the diagnosis and treatment of MS patients. The
duration of the intervention was 6 months: 5 hours a
week (2 weekly sessions of 1.5 hours in the consulting
room, and 2 hours in the classroom). This was developed
in the following manner: [7]
1) Classroom activities: Based on a previously se-
lected program of subjects and readings, during the cla-
ssroom sessions the following types of activities were
carried out:
 Theoretical subject presentation by teacher (40
minutes)
 Discussion in small groups: students discussed
the subject presented one session before, including
analytical revision of literature. Each group ana-
lyzed points of agreement and disagreement (30
minutes).
 Debate: after the small-group discussion exercise,
students presented to the entire group a condensed
version of their ideas, comments, discrepancies and
arguments, which they contrasted with other ver-
sions (30 min).
 Review of clinical cases. Physicians presented a
clinical case in a rotary manner allowing for eve-
ryone to have the opportunity to participate.
 Commented critical review of the literature, discus-
sion and analysis of clinical cases.
2) Activities at the medical consulting room: The
whole purpose is to provide care to patients with MS to
strengthen the risk factor identification. The consulta-
tions were carried out by the group of instructors, ensur-
ing participation of all physicians included in the study.
Diverse scientific texts and articles were reviewed for
the construction of theoretical contents and pedagogical
materials. The strategy was developed by one physician
specialized in Internal Medicine holding a Master’s de-
gree in Public Health Sciences, one physician special-
ized in Family Medicine holding a Master’s degree in
Medical Sciences, one physician specialized in Nutrition
holding a Master’s degree in Education, and two general
physicians with Master’s degrees in Nutrition; all ex-
perienced in investigation projects.

C. E. Cabrera-Pivaral et al. / Health 3 (2011) 626-630
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2.4. Statistical Analysis
In the case of dimensional variables, data is shown as a ±
average standard deviation (SD), or mean (25% - 75%
percentile), according to parametrical or non-paramet-
rical distribution respectively. Nominal variables are
shown as numbers or percentages. Comparisons between
groups with and without educative intervention were
established through square chi in the case of nominal or
categorical variables; for quantitative variables, through
the Mann-Whitney U-test for two independent samples.
For calculating explainable scores by random effect, the
Perez-Padilla and Viniegra Formula were utilized [12].
For changes in medical ability, the Wilcoxon rank test
(before-after) was utilized. A value of p < 0.05 was con-
sidered to be significant; however, it is preferable to ex-
press exact numbers. For data analysis the SPSS statis-
ticcal package for Windows, version 10.0, was utilized.
3. RESULTS
3.1. Clinical Ability
40 primary-care physicians willing to participate were
included, 21 from FCU (A) who received educative in-
tervention, and 19 from FCU (B) who corresponded to
the control group.
Table 1 shows socio-demographic characteristics of
the total sample. Age averages were similar in both
groups, 43 ± 8 vs. 44 ± 6 years respectively (p = 0.85).
There was no significant difference in gender distribu-
tion between groups (p = 0.94). 86% of physiccians in
the experimental group have a specialty, vs. 78% in the
control group, this being a non-significant difference
(p = 0.73). There were no significant differences be-
tween work category and seniority within IMSS (p =
0.53 and 0.34, respectively).
The clinical ability Risk factor identification level ob-
tained for each group is shown in Table 2; the base
global measurement score for the control group was 27
with a range of 7 to 27, and 26 for the experimental
group with a range of 7 to 32; it is observed that no sig-
nificant difference was found during base measurement
between the different levels of clinical ability among
groups (p = 0.84); both the experimental and control
groups have a higher frequency of regular level (33.3%
vs. 36.8%, respectively). At the end of follow-up a sig-
nificant increase of 9.5% was observed in the experi-
mental group of physicians obtaining a high ability level;
whereas in the control group no physician reached that
grade. The proportion of physicians with a regular abil-
ity level increased in the experimental group (from
33.3% to 52.4% at the end of follow-up), whereas in the
control group it decreased from 36.8% to 31.6%, thus
increasing proportion of low level physicians from
26.3% to 47.4%.
3.2. Comparison of Mean Scores Obtained
by Indicators
Indicator-obtained differences for each group are
shown in Table 2. During base measurement, the indica-
tors for identification of risk factors result showed no
Table 1. Comparison of socio-demographic characteristics of family physicians between groups (N 40).
Variable FCU (A) Educative Intervention (N 21) FCU (B) Without Educative Intervention (N 19) p value
Age (years) 43 ± 8 44 ± 6 0.81
Gender, N:
Male 12 (57%) 11 (58%) 0.96
Female 9 (43%) 8 (42%)
Specialization, N 18 (86%) 14 (78%) 0.74
Labor category, N
Permanent 16 (76%) 16 (84%) 0.52
Temporary 5 (24%) 3 (16%)
Seniority 12 ± 7 14 ± 7 0.32
Table 2. Comparison of clinical ability level by scores obtained from a control group and an experimental group of physicians.
Experimental group Control group
Risk factor identification Level (Score) Basal* Final
** Basal Final
Global (Median/Range)
High (33-40)
Regular (25- 32)
Low (17-24)
Very low (9-16)
Explainable by random effect <8
26 (7-32)
0 (0%)
7 (33.3%)
5 (23.8%)
6 (28.6%)
3 (14.3%)
29 (20-33) *
3 (14.3%)†**
11 (52.4%)†**
7 (33.3%)†**
0 (0%)†**
0 (0%)†
27 (7-27)
0 (0%)
7 (36.8%)
5 (26.3%)
6 (31.6%)
1 (5.3%)
27 (12-26)
0 (0%)
6 (31.6%)
9 (47.4%)
4 (21.1%)
0 (0%)
† p 0.05 vs. base of same group; ** p < 0.05 vs. control group in same evaluation; *p ≤ 0.05 vs. base of same group. <

C. E. Cabrera-Pivaral et al. / Health 3 (2011) 626-630
Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
629629
significant difference among groups.
At the end of the intervention, the experimental group
had increased indicators in the identification of risk fac-
tors. For the control group, none of the indicators
showed statistically significant differences when relating
initial and final measurements.
4. DISCUSSION
With regard to the educative process, it is acknowl-
edged that both groups at the beginning of the educative
intervention showed a homogeneous distribution in rela-
tion to competence levels of clinical ability; after the
educative intervention in the control group, a downward
displacement was observed without presenting any cases
explainable by chance, where the control group showed
no modifications concerning the levels of product study
variables of informative rote learning, characterized
within traditional teaching-learning models [7].
In the experimental group, an upward displacement
was observed in competence levels of clinical ability
concerning decision making in patient management. It is
important to recognize that only one physician is at a
very low level and/or random and that there exists a 30%
increase in regular level and the appearance of two phy-
sicians in the high level [17,18].
While the communicative-participative strategy which
was offered to the family physicians in the experimental
group was marked by reflection-action over the inter-
pretation of risk factors, similar data to those reported by
Gonzalez C.A. [3], measuring the effect of an educa-
tive intervention within critical readings of investigation
reports..
This educative strategy, an alternative to the tradi-
tional model, allows the advancement of family physic-
cians at different levels, because educative methodology
fosters physicians’ participation in the construction of
their own knowledge generated by confronting difficult,
real clinical cases.
The advantage observed at the different levels of the
experimental group reflects the impact of the alternative
educative program which needs to be a programmatic
guide for future educative interventions for health work-
ers seeking to transform their own clinical practice
without forgetting that, to influence behavioral change in
patients with MS, the cultural sphere where it is devel-
oped should be considered.
Of upmost importance is the proposal to modify the
educative processes concerning the formation of human
resources as well as the continuous education to transfer
the clinical practice to higher levels of ability; this de-
mands the adequate living reality as the first level of
attention with the objective of delivering integral ser-
vices.
The utilization of human behavior measurement in-
struments along with clinical practice have become more
and more useful to assess the processes of human re-
sources formation and service delivery. These kinds of
instruments aim to discriminate dominance over one
particular issue, namely, competence of clinical ability,
which demands a level of reliability within its construc-
tion to avoid information biases; characteristics which
this study covers and which allows control of said biases
together with discrimination of the diverse levels of
clinical ability. It must be recognized, however, that this
system does not allow identification of qualitative vari-
ables that could be generating a favorable difference
which is assumed to be controlled through homogeniza-
tion of groups [19,20].
The alternative educative model used led to the in-
volvement of family physicians through recognition of
the creation of their own knowledge in a mainstream
manner and which unchained and directed refined pro-
posals in the clinical practice of MS measured by self-
criticism.
It is acknowledged that the experimental group was
formed by family physicians, the majority of whom were
specialized in family medicine, and that this could have
an impact on the educative strategy in the levels of
clinical ability; before the intervention, however, such
levels were homogeneous, which reflects the initial con-
trol for these variables, thus all improvements in the ex-
perimental group were due to the effect of educative
intervention and not to a probable confusion variable.
The participation of the experimental group leader
was due to the learning commitment in the reflection-
action mode, and who was responsible for developing
strategies to promote the family physicians’ participation
with the aim of building their own knowledge from re-
flection-action patterns which were lacking in the con-
trol group.
Finally, the utilization of educative investigation as a
learning tool (which allows feedback of educative proc-
ess) allows consolidation of educative strategies which
directs family physicians’ participation within formative
schemes for their clinical practice, which contribute to
the development of competence concerning clinical abil-
ity in its different levels, and it can be applied not only
in the matter of a patient with metabolic syndrome but in
any other condition which requires the physician’s clini-
cal ability to reach an accurate diagnosis and timely
treatment.
Because the prevalence of MS in Mexico is high as in
other countries; as well as the cardiovascular and meta-
bolic consequences of this syndrome, that can be gener-
ated by the lack of an early diagnosis and timely treat-
ment, it is recommended that the first contact physicians

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Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
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be trained regularly through such educational strategies
with the aim of providing the most appropriated tools for
increasing their clinical competence as reflected in a
better decision making in benefit of their patients.
REFERENCES
[1] Lerman, G.I., Aguilar-Salinas, C.A., Gómez-Pérez, F.J.,
Reza, A. A., Hernández, J. S. (2004) El síndrome meta-
bólico, posición de la Sociedad Mexicana de nutrición y
endocrinología, sobre la definición, fisiopatología y
diagnóstico. Características del síndrome metabólico en
México. Revista de Endocrinología y Nutrición, 12,
109-122.
[2] Luquez, H., De Loredo, L., Madoery, R.J. (2005) Sínd-
rome Metabólico: prevalencia en dos comunidades de
Cordóba Argentina de acuerdo con definiciones de ATP
III y OMS. Revista de la Federacion Argentina de
Cardiologia, 43, 80-95.
[3] Rodríguez, P.A., Sánchez, L.M., Martínez, V.L. (2002)
Síndrome metabólico. Rev Cub Endocrinol, 13, 238-252.
[4] Dekker, J. M., Girmain, C., Rhodes, T., Nipjels, G. (2005)
Metabolic Síndrome and 10 year cardiovascular disease
risk in the Hoorn study. Circulation, 112, 666-673.
[5] Gutiérrez, G.S.N., Aguilar, M.E., Viniegra, V.L. (2001)
Validación de un instrumento para evaluar la compet-
encia clínica del médico familiar. Revista Medica del
Instituto Mexicano del Seguro Social, 37, 201-210.
[6] Chávez, V., Aguilar, M. (2002) Aptitud clínica en el
manejo de la familia, en residentes de Medicina Familiar.
Revista Medica del Instituto Mexicano del Seguro Social,
40, 477-481.
[7] Burr, W.A. (2004) Diabetes UK. Diabetic Medicine, 21,
1-16
[8] Viniegra, V.L., Pérez-Padilla, J.L., (1991) JR. El desafío
de la evaluación de la competencia clínica, Revista
Medica del Instituto Mexicano del Seguro Social, 43,
87-95.
[9] Larios, M.H., Trejo, M.J.A., Cortés, G.T. (1998) Eva-
luación de la competencia clínica. Revista Medica del
Instituto Mexicano del Seguro Social, 36, 77-82.
[10] Rothman, A. I., Blackmore, D., Cohen, R., Reznic, R.
(1996) The consistency and uncertainty in examiners’
definitions of pass/fail performance on OSCE stations.
Evaluation & the Health Professions, 16, 322-332.
[11] Garfias, G.G., Aguilar, M.E., Viniegra, V.L. (1997) Cómo
explorar las aptitudes de los médicos residentes de
traumatología y ortopedia en traumatismo cráneo ence-
fálico. Revista de la Federacion Argentina de Ca rdiologia,
35, 233-237.
[12] Carlos, A.H., Miriam, D., Sánchez, I., Pérez, C.P., Nor-
berto, E. (2004) Aptitud clínica durante el internado de
pregrado en hospitales generales. Revista de la Fede-
racion Argentina de Cardiologia, 42, 469-476.
[13] Searle, J. (2000) Defining competency-the role of stan-
dard setting. Med Educ, 34, 363-366.
[14] Gadner, W., Nutting, P.A., Kelleher, K.J. (1996) Does the
family Apgar effectively measure family functioning?
Aten Primaria, 17, 338-341.
[15] Sánchez, T.E., Pérez, C.L., Navarro, L.M.E., Kum-
azagua, I.M., Vázquez-Garibay, E. (1994) Dinámica
Familiar: Metodología para su evaluación. American
Journal of Disease, 7, 48-52.
[16] Lara, E.A., Carrillo, T.J., Carrasco, M.M. (2005) Nutri-
ción en el Síndrome Metabólico. Annual Review del
Colegio de Medicina Interna de México; 1ª Edición,
México, Editorial Intersistemas.
[17] González, C.A., Sánchez, Z.M., Elizondo, A.S. Malanco,
H.L. (2005) Inflamación y resistencia a la insulina, su
papel en el desarrollo del síndrome meta-bólico. Annual
Review del Colegio de Medicina Interna de México; 1ª
Edición, México, Editorial Intersistemas.
[18] Sabido, S.M.C., Viniegra, V.L. (2000) Competencia y
desempeño en la evaluación del médico: estudio con
pacientes diabéticos en el primer nivel de atención. En:
Viniegra VL. La investigación en la educación. Papel de
la teoría y de la observación. México, IMSS, 1ª Edición,
pp. 251-270.
[19] Vázquez-Garibay, E., Sánchez, T.E, Navarro, L.M.E.,
Romero, V.E., Pérez, C.L., Kumazagua, I.M.R. (2003)
Instrumento de Medición de la dinámica de la familia
nuclear mexicana. Un enfoque cuantitativo. Boletín
médico del Hospital Infantil de México, 60, 33-52.
[20] SECRETARIA DE SALUD: Reglamento de la Ley
General de Salud en materia de investigación para la
salud. (1990) México, D.F. Editorial SSA.
http://salud.gob.mx/unidades/cdi/nom/compi/rlgsmis.htl
m