A framework to teach self-reflection for the remedial resident

Background: Regardless of the area of deficiency, be it in knowledge, skills or attitudes, residents requiring remediation are rarely self-identified. This illustrates a diminished ability for self-reflection. Self-reflection is a cornerstone of adult education. During the remediation process, the remediation curriculum needs to emphasize self-reflection.

Aims: How can one structure self-reflection in a remediation curriculum?

Methods: This article describes how to adapt and apply environmental scanning for remedial residents.

Results: Environmental scanning is a rigorous and well-developed business approach that can be adapted for personal continuous quality improvement to foster self-reflection in medical trainees. There are often already existing tools which can form the foundation for regular reflection in medical education using an environmental scanning structure.

Conclusions: Environmental scanning can be thought of as a structured approach to internal and external reflections.

Modification of an OSCE format to enhance patient continuity in a high-stakes assessment of clinical performance

Background: Traditional Objective Structured Clinical Examinations (OSCEs) are psychometrically sound but have the limitation of fragmenting complex clinical cases into brief stations. We describe a pilot study of a modified OSCE that attempts to balance a typical OSCE format with a semblance of a continuous, complex, patient case.

Methods: Two OSCE scenarios were developed. Each scenario involved a single standardized patient and was subdivided into three sequential 10 minute sections that assessed separate content areas and competencies. Twenty Canadian PGY-4 internal medicine trainees were assessed by trained examiner pairs during each OSCE scenario. Paired examiners rated participant performance independent of each other, on each section of each scenario using a validated global rating scale. Inter-rater reliabilities and Pearson correlations between ratings of the 3 sections of each scenario were calculated. A generalizability study was conducted. Participant and examiner satisfaction was surveyed.

Results: There was no main effect of section or scenario. Inter-rater reliability was acceptable. The g-coefficient was 0.68; four scenarios would achieve 0.80. Moderate correlations between sections of a scenario suggest a possible halo effect. The majority of examiners and participants felt that the modified OSCE provided a sense of patient continuity.

Conclusions: The modified OSCE provides another approach to the assessment of clinical performance. It attempts to balance the advantages of a traditional OSCE with a sense of patient continuity.

Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes

OBJECTIVES: To determine whether a reduction in working hours of doctors in postgraduate medical training has had an effect on objective measures of medical education and clinical outcome.

DESIGN: Systematic review.

DATA SOURCES: Medline, Embase, ISI Web of Science, Google Scholar, ERIC, and SIGLE were searched without language restriction for articles published between 1990 and December 2010. Reference lists and citations of selected articles.

STUDY SELECTION: Studies that assessed the impact of a change in duty hours using any objective measure of outcome related to postgraduate medical training, patient safety, or clinical outcome. Any study design was eligible for inclusion.

RESULTS: 72 studies were eligible for inclusion: 38 reporting training outcomes, 31 reporting outcomes in patients, and three reporting both. A reduction in working hours from greater than 80 hours a week (in accordance with US recommendations) does not seem to have adversely affected patient safety and has had limited effect on postgraduate training. Reports on the impact of European legislation limiting working hours to less than 56 or 48 a week are of poor quality and have conflicting results, meaning that firm conclusions cannot be made.

CONCLUSIONS: Reducing working hours to less than 80 a week has not adversely affected outcomes in patient or postgraduate training in the US. The impact of reducing hours to less than 56 or 48 a week in the UK has not yet been sufficiently evaluated in high quality studies. Further work is required, particularly in the European Union, using large multicentre evaluations of the impact of duty hours' legislation on objective educational and clinical outcomes.

Osteopathic Manipulative Treatment and Vertigo

OBJECTIVE: To assess the safety and feasibility of studying osteopathic manipulative treatment and its potential effectiveness for patients with vertigo.
DESIGN: A nonrandomized pilot study.
SETTING: Outpatient clinic affiliated with a teaching hospital and osteopathic medical school.
PATIENTS: The subjects were older than 18 years of age, with the diagnosis of vertigo for longer than 3 months.
INTERVENTION: The patients were treated with osteopathic manipulative treatment (OMT).
MAIN OUTCOME MEASUREMENTS: Treatment effectiveness was measured with the use of the Dizziness Handicap Inventory (DHI), a validated symptom inventory. Intensity and duration of adverse effects after OMT were used to measure study safety.
RESULTS: Of the 18 patients who were recruited all 18 (100%) met the inclusion criteria and were enrolled in the study. Sixteen patients (88.9%) completed the treatment course with OMT, and data with respect to the DHI were obtained from all 16 (100%). Significant improvement (P<.001) in total and subcomponent DHI scores was observed after completion of treatment. Of the 8 patients with moderate pretest scores, 7 (87.5%) had mild post-test scores after undergoing OMT, and of the 8 patients with severe pretest scores, 4 (50%) had mild post-test scores. Of the 18 enrolled patients, 3 (16.7%) experienced an exacerbation of their vertigo, and 5 (27.8%) experienced muscle soreness after OMT. These adverse effects were mild and transient, not lasting longer than 24 hours.
CONCLUSIONS: This study showed that OMT is generally well tolerated in patients with vertigo. It also demonstrated that it is feasible to recruit a population of patients with vertigo who can complete a course of OMT and collect data by using the DHI. A randomized control trial that examines the efficacy of OMT in patients with vertigo is warranted, given that OMT may be a reasonable treatment for vertigo and the functional impairment associated with it.

Effect of pedal pump and thoracic pump techniques on intracranial pressure in patients with traumatic brain injuries

CONTEXT: Although osteopathic manipulative treatment (OMT) is used to manage myriad conditions, there has been some hesitation regarding the safety of applying OMT to patients with intracranial injuries or elevated intracranial pressure (ICP).
OBJECTIVE: To assess the safety of two OMT techniques--pedal pump and thoracic pump--on ICP and cerebral perfusion pressure (CPP) in patients with traumatic brain injuries (Glasgow Coma Scale score < or =8).
METHODS: We prospectively enrolled consecutive patients admitted to the intensive care unit (ICU) for traumatic brain injury. Patients between the ages of 18 and 75 years and with abnormal CT scans were included in the present study. Patients with baseline ICP values of 20 mm Hg or lower were assigned to group 1, and those with ICP levels greater than 20 mm Hg, group 2. Patients underwent continuous ICP and CPP monitoring, with ICP measured using a ventricular catheter and fiber optic device. Values of ICP and CPP were recorded at baseline, during application of the OMT techniques, and 5 minutes after the two OMT techniques were completed. Patients received up to three treatment cycles. Ventricular drains remained open (stopcock open) during OMT, allowing continued cerebral spinal fluid drainage, except for brief periodic closures (stopcock closed) every minute to register accurate ICP values. Statistical analysis was performed using a dependent t test with repeated measures.
RESULTS: Twenty-four comatose patients, aged 18 to 69 years, received a total of 50 sessions of pedal pump and thoracic pump techniques. In group 1 patients, a slight decrease in ICP values (mean, -0.586 mm Hg) and an increase in CPP values (mean, 1.1613 mm Hg) was noted post-OMT. Patients in group 2 also had decreased mean ICP values (-1.20 mm Hg) and increased mean CPP values (2.2105 mm Hg). Changes were not statistically significant in either group.
CONCLUSION: According to the present limited study, pedal pump and thoracic pump techniques may be used safely in patients with severe brain injuries.

Effect of osteopathy in the cranial field on visual function

CONTEXT: The effects of osteopathy in the cranial field on visual function-particularly on changes in the visual field and on the binocular alignment of the eyes-have been poorly characterized in the literature. The authors examined whether osteopathy in the cranial field resulted in an immediate, measurable change in visual function among a sample of adults with cranial asymmetry.
STUDY DESIGN: Randomized controlled double-blinded pilot clinical trial.
SUBJECTS: Adult volunteers between ages 18 and 35 years who were free of strabismus or active ocular or systemic disease were recruited. Inclusion criteria were refractive error ranging between six diopters of myopia and five diopters of hyperopia, regular astigmatism of any amount, and cranial somatic dysfunction.
INTERVENTION: All subjects were randomly assigned to the treatment or control group. The treatment group received a single intervention of osteopathy in the cranial field to correct cranial dysfunction. The control group received light pressure of a few ounces of force applied to the cranium without osteopathic manipulative treatment.
MEASUREMENTS: Preintervention and postintervention optometric examinations consisted of distant visual acuity testing, Donder push-up (ie, accommodative system) testing, local stereoacuity testing, pupillary size measurements, and vergence system (ie, cover test with prism neutralization, near point of convergence) testing. Global stereoacuity testing and retinoscopy were performed only in preintervention to determine whether subjects met inclusion criteria. Analysis of variance (ANOVA) was performed for all ocular measures.
RESULTS: Twenty-nine subjects completed the trial-15 in the treatment group and 14 in the control group. A hierarchical ANOVA revealed statistically significant effects within the treatment group and within the control group (P <.05) in distance visual acuity of the right eye (OD) and left eye (OS), local stereoacuity, pupillary size measured under dim illumination OD and OS, and near point of convergence break and recovery. For the treatment group vs the control group, a statistically significant effect was observed in pupillary size measured under bright illumination OS (P <.05).
CONCLUSIONS: The present study suggests that osteopathy in the cranial field may result in beneficial effects on visual function in adults with cranial asymmetry. However, this finding requires additional investigation with a larger sample size and longer intervention and follow-up periods.

When to consider osteopathic manipulation

Consider osteopathic manipulation for low back pain that has not responded to customary care, and other musculoskeletal pain such as headache or neck pain.

Basic Surgical Skills Testing for Junior Residents

Basic Surgical Skills Testing for Junior Residents
BACKGROUND: The American College of Surgeons/Association of Program Directors in Surgery Phase 1 Curriculum (ACS/APDS) includes evaluation of basic surgical skills for junior residents. It is unclear if basic surgical skills evaluation is incorporated into residency curricula or used for resident advancement decisions. Our aim was to identify the perceptions of general surgery program directors (PDs) on the importance of basic surgical skills training and evaluation.
STUDY DESIGN: Thirty PDS were invited to participate in a telephone interview. PDs were chosen for diversity of program location and size and asked to comment on their use and perceptions of basic surgical skills curricula, and evaluation.
RESULTS: Twenty-two interviews were conducted with 23 of the total 30 invited PDs who agreed to participate. The mean number of residents graduating annually was 6 (range 2 to 12) per program. Ten of 22 (45%) PDs used the ACS/APDS curriculum, and 5 (23%) PDs were unaware of its existence. Only 4 programs (18%) perform formal basic surgical skills evaluation with mandatory remediation. No PD would either prevent residents with demonstrable poor basic surgical skills from going to the operating room or use poor basic surgical skills as a reason to deny promotion. One institution required evidence of satisfactory central line placement skills for credentialing. Obstacles to implementation of basic surgical skills included a lack of time, resources, and validated tests. Sixteen (73%) PDs saw some value in skills evaluation generally, but only 41% saw basic surgical skills evaluation as important for junior residents.
CONCLUSIONS: Implementation of a summative evaluation of skills will require considerable resources for PDs. This study suggests that scarce resources might be more usefully directed toward evaluation of operative skills of senior residents.

Surgical activity of first-year Canadian neurosurgical residents

Surgical activity of first-year Canadian neurosurgical residents

INTRODUCTION: Surgical activity is probably the most important component of surgical training. During the first year of surgical residency, there is an early opportunity for the development of surgical skills, before disparities between the skill sets of residents increase in future years. It is likely that surgical skill is related to operative volumes. There are no published guidelines that quantify the number of surgical cases required to achieve surgical competency. The aim of this study was to describe the current trends in surgical activity in a recent cohort of first-year Canadian neurosurgical trainees.
METHODS: This study utilized retrospective database review and survey methodology to describe the current state of surgical training for first-year neurosurgical trainees. A committee of five residents designed this survey in an effort to capture factors that may influence the operative activity of trainees.
RESULTS: Nine out of a cohort of 20 first-year Canadian neurosurgical trainees that began training in July of 2008 participated in the study. The median number of cases completed by a resident during the initial three month neurosurgical rotation was 66, within which the trainee was identified as the primary surgeon in 12 cases. Intracranial hemorrhage and cerebrospinal fluid diversion procedures were the most common operations to have the trainee as primary surgeon.
CONCLUSION: Based on this pilot study, it appears that the operative activity of Canadian first-year residents is at least equivalent to the residents of other studied training systems with respect to volume and diversity of surgical activity.

Surgical resident education: what is the department's price for commitment

Surgical resident education: what is the department's price for commitment

OBJECTIVE: The current recession has impacted all aspects of our economy. Some residency programs have experienced faculty salary cuts, furlough days, and cessation of funding for travel to academic meetings. This milieu forced many residency programs to reevaluate their commitment to resident education, particularly for those expenses not provided for by Direct Medical Education (DME) and Indirect Medical Education (IME) funds. The purpose of this study was to determine what price a Department of Surgery pays to fulfill its commitment to resident education.
DESIGN: A financial analysis of 1 academic year was performed for all expenses not covered by DME or IME funds and is paid for by the faculty practice plan. These expenses were categorized and further analyzed to determine the funds required for resident-related scholarly activity.
SETTING: A university-based general surgery residency program.
PARTICIPANTS: Twenty-eight surgical residents and a program coordinator.
RESULTS: The departmental faculty provided $153,141 during 1 academic year to support the educational mission of the residency. This amount is in addition to the $1.6 million in faculty time, $850,000 provided by the federal government in terms of DME funds, and $14 million of IME funds, which are distributed on an institutional basis. Resident presentations at scientific meetings accounted for $49,672, and program coordinator costs of $44,190 accounted for nearly two-thirds of this funding. The departmental faculty committed $6400 per categorical resident.
CONCLUSIONS: In addition to DME and IME funds, a department of surgery must commit significant additional monies to meet the educational goals of surgical residency.

Hematology/oncology fellows' training in palliative care

Hematology/oncology fellows' training in palliative care: Results of a national survey

BACKGROUND: Palliative care is recognized as integral to the practice of oncology, yet many oncologists report inadequate training in critical palliative care domains, such as symptom management, psychosocial care, and communication skills. The authors of this report sought to assess the quantity and quality of palliative care education within oncology fellowships.
METHODS: Second-year oncology fellows completed a 104-item survey that was modified and adapted from a national survey of medical students and residents. Items allowed comparison between palliative care and nonpalliative care topics.
RESULTS: Of 402 eligible fellows, 63.2% responded (n = 254). Respondents were: 52% men, 62% Caucasian, and 64% US medical school graduates. Twenty-six percent had completed a palliative care rotation. Fellows rated the overall quality of fellowship teaching more highly than teaching on palliative care (3.7 v 3.0 on a 1-5 scale; t = 10.2; P < .001). Rates of being observed (81%) and receiving feedback (80%) on an end-of-life communication skill were high. Psychosocial needs of patients received some attention: Fifty-seven percent of fellows reported that they were conveyed as a core competency, but only 32% of fellows received explicit education on assessing and managing depression at the end of life. Fellows rarely reported receiving explicit education on opioid rotation (33%). Fellows scored a median of 2 of 4 items that tested basic palliative care knowledge, and only 23% correctly performed an opioid conversion.
CONCLUSIONS: Fellows rated the quality of palliative care education as inferior to overall oncology training and may benefit from more teaching on pain management, psychosocial care, and communication skills. Cancer 2011;. © 2011 American Cancer Society.

Using N-of-1 trials to improve patient management and save costs

Using N-of-1 trials to improve patient management and save costs

BACKGROUND: N-of-1 trials test treatment effectiveness within an individual patient.

OBJECTIVE: To assess (i) the impact of three different N-of-1 trials on both clinical and economic outcomes over 12 months and (ii) whether the use of N-of-1 trials to target patients' access to high-cost drugs might be cost-effective in Australia.
DESIGN: Descriptive study of management change, persistence, and costs summarizing three N-of-1 trials.
PARTICIPANTS: Volunteer patients with osteoarthritis, chronic neuropathic pain or ADHD whose optimal choice of treatment was uncertain.
INTERVENTIONS: Double-blind cyclical alternative medications for the three conditions.
MEASURES: Detailed resource use, treatment and health outcomes (response) data collected by postal and telephone surveys immediately before and after the trial and at 3, 6 and 12 months. Estimated costs to the Australian healthcare system for the pre-trial vs. 12 months post-trial.
RESULTS: Participants persisting with the joint patient-doctor decision 12 months after trial completion were 32% for osteoarthritis, 45% for chronic neuropathic pain and 70% for the ADHD trials. Cost-offsets were obtained from reduced usage of non-optimal drugs, and reduced medical consultations. Drug costs increased for the chronic neuropathic pain and ADHD trials due to many patients being on either low-cost or no pharmaceuticals before the trial.
CONCLUSIONS: N-of-1 trials are an effective method to identify optimal treatment in patients in whom disease management is uncertain. Using this evidence-based approach, patients and doctors tend to persist with optimal treatment resulting in cost-savings. N-of-1 trials are clinically acceptable and may be an effective way of rationally prescribing some expensive long-term medicines.

Radiology Resident Teaching Skills Improvement

Radiology Resident Teaching Skills Improvement: Impact of a Resident Teacher Training Program

Rationale and Objectives: Teaching is considered an essential competency for residents to achieve during their training. Instruction in teaching skills may assist radiology residents in becoming more effective teachers and increase their overall satisfaction with teaching. The purposes of this study were to survey radiology residents’ teaching experiences during residency and to assess perceived benefits following participation in a teaching skills development course.

Materials and Methods: Study participantswere radiology residentswithmembership in the American Alliance of AcademicChief Residents in Radiology or the Siemens AUR Radiology Resident Academic Development Programwho participated in a 1.5-hour workshop on teaching skills developmentat the 2010 Association of University Radiologists meeting. Participants completed a self-administered, precourse questionnaire that addressed their current teaching strategies, as well as the prevalence and structure of teaching skills training opportunities at their institutions. A second postcourse questionnaire enabled residents to evaluate the seminar and assessed new knowledge and skill acquisition.

Results: Seventy-eight residents completed the precourse and postcourse questionnaires. The vast majority of respondents indicated that they taught medical students (72 of 78 [92.3%]). Approximately 20% of residency programs (17 of 78) provided residents with formal didactic programs on teaching skills. Fewer than half (46.8%) of the resident respondents indicated that they received feedback on their teaching from attending physicians (36 of 77), and only 18% (13 of 78) routinely gave feedback to their own learners. All of the course participants agreed or strongly agreed that this workshop was helpful to them as teachers.

Conclusions: Few residency programs had instituted resident teacher training curricula. A resident teacher training workshop was perceived as beneficial by the residents, and they reported improvement in their teaching skills.

Clinician-Educator Pathway for Radiology Residents

Clinician-Educator Pathway for Radiology Residents

Faculty clinician-educator tracks have become increasingly common at US academic medical centers. Although many radiology faculty members belong to such tracks, there is little training in radiology residencies to prepare residents to take on these roles. The authors present a summary of a novel radiology residency clinician-educator pathway developed and piloted at their institution. The key components of the pathway include protected time to work on a substantive education project and a small number of high-quality didactic lectures. Publication or presentation in some form is expected. The pathway includes regular mentorship from highly regarded clinician-educators, as well as didactic training in education techniques and skills. A formal application process was established, as were methods of evaluation during and after the experience.

Business Education for Radiology Residents

Business Education for Radiology Residents: The Value of Full-time Business Educators

This article reports the design, implementation, and evaluation of a new business course for radiology residents taught by business school faculty.

A Dedicated General Competencies Curriculum for Radiology Residents

A Dedicated General Competencies Curriculum for Radiology Residents: Development and Implementation

Rationale and Objectives: The Accreditation Council on Graduate Medical Education (ACGME) through its Outcome Project requires training programs in all medical specialties to integrate six general competencies into residency training: patient care, medical knowledge, professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice. In response, a required, or dedicated general competencies rotation for diagnostic radiology residents was instituted.

Materials and Methods: We describe the development and implementation of this rotation. The rotation augments the core curriculum, with primary emphasis placed on resident-initiated quality improvement (QI) and quality assurance (QA) projects.

Results: Between academic years 2003 and 2009 diagnostic radiology residents completed 38 QI/QA projects and performed clinical float coverage for the department. Residents met requirements of the systems-based practice and practice-based learning competency domains. In this process, residents improved their medical knowledge, interpersonal communication skills, professionalism, and provided patient care.

Conclusions: A dedicated general competencies rotation can be successfully implemented, and complement the requirements of the core curriculum. In combination with coverage for clinical services, the rotation makes a substantive contribution to resident education

to further the goal of improved patient care.

Objective Structured Clinical Examinations (OSCEs), Psychiatry and the Clinical Assessment of Skills and Competencies (CASC)

Objective Structured Clinical Examinations (OSCEs), Psychiatry and the Clinical Assessment of Skills and Competencies (CASC)

Background

The Objective Structured Clinical Examination (OSCE), originally developed in the 1970's, has been hailed as the "gold standard" of clinical assessments for medical students and is used within medical schools throughout the world. The Clinical assessment of Skills and Competencies (CASC) is an OSCE used as a clinical examination gateway, granting access to becoming a senior Psychiatrist in the UK. Discussion: Van der Vleuten's utility model is used to examine the CASC from the viewpoint of a senior psychiatrist. Reliability may be equivalent to more traditional examinations. Whilst the CASC is likely to have content validity, other forms of validity are untested and authenticity is poor. Educational impact has the potential to change facets of psychiatric professionalism and influence future patient care. There are doubts about acceptability from candidates and more senior psychiatrists. Summary: Whilst OSCEs may be the best choice for medical student examinations, their use in post graduate psychiatric examination in the UK is subject to challenge on the grounds of validity, authenticity and educational impact.

Training satisfaction for subspecialty fellows in internal medicine

Training satisfaction for subspecialty fellows in internal medicine: Findings from the Veterans Affairs (VA) Learners' Perceptions Survey

Background

Learner satisfaction assessment is critical in the design and improvement of training programs. However, little is known about what influences satisfaction and whether trainee specialty is correlated. A national comparison of satisfaction among internal medicine subspecialty fellows in the Department of Veterans Affairs (VA) provides a unique opportunity to examine educational factors associated with learner satisfaction. We compared satisfaction across internal medicine fellows by subspecialty and compared factors associated with satisfaction between procedural versus non-procedural subspecialty fellows, using data from the Learners' Perceptions Survey (LPS), a validated survey tool.

Methods

We surveyed 2,221 internal medicine subspecialty fellows rotating through VA between 2001 and 2008. Learners rated their overall training satisfaction on a 100-point scale, and on a five-point Likert scale ranked satisfaction with items within six educational domains: learning, clinical, working and physical environments; personal experience; and clinical faculty/preceptor.

Results

Procedural and non-procedural fellows reported similar overall satisfaction scores (81.2 and 81.6). Non-procedural fellows reported higher satisfaction with 79 of 81 items within the 6 domains and with the domain of physical environment (4.06 vs. 3.85, p<0.001). Satisfaction with clinical faculty/preceptor and personal experience had the strongest impact on overall satisfaction for both. Procedural fellows reported lower satisfaction with physical environment.

Conclusions

Internal medicine fellows are highly satisfied with their VA training. Nonprocedural fellows reported higher satisfaction with most items. For both procedural and non-procedural fellows, clinical faculty/preceptor and personal experience have the strongest impact on overall satisfaction.

What are the learning outcomes of a short postgraduate training course in dermatology for primary care doctors?

What are the learning outcomes of a short postgraduate training course in dermatology for primary care doctors?

Background

There are increasing expectations on primary care doctors to shoulder a bigger share of

care for patients with common dermatological problems in the community. This study

examined the learning outcomes of a short postgraduate course in dermatology for

primary care doctors.

Methods

A self-reported questionnaire developed by the research team was sent to the Course

graduates. A retrospective design was adopted to compare their clinical practice

characteristics before and after the Course. Differences in the ratings were analysed

using the nonparametric Wilcoxon signed rank test to evaluate the effectiveness of the

Course in various aspects.

Results

Sixty-nine graduates replied with a response rate of 43.9% (69/161). Most were

confident of diagnosing (91.2%) and managing (88.4%) common dermatological

problems after the Course, compared to 61.8% and 58.0% respectively before the

Course. Most had also modified their approach and increased their attention to patients

with dermatological problems. The number of patients with dermatological problems

seen by the graduates per day showed significant increase after the Course, while the

average percentage of referrals to dermatologists dropped from 31.9% to 23.5%. The

proportion of graduates interested in following up patients with chronic dermatological

problems increased from 60.3% to 77.9%.

Conclusions

Graduates of the Course reported improved confidence, attitudes and skills in treating

common dermatological problems. They also reported to handle more patients with

common dermatological problems in their practice and refer fewer patients.