Stroke physician versus stroke neurologist: can anyone thrombolyse?

BACKGROUND/AIM

The aim of this study is to compare the outcomes of thrombolysis under standard clinical settings between subjects treated by a stroke neurologist versus those treated by a non-neurologist stroke physician.

METHODS

Single-centre, observational cohort study of subjects thrombolysed in a calendar year, stratified according to the physician type authorising thrombolysis. Endpoints measured include proportion of subjects with symptomatic intracranial haemorrhage, door-to-needle time, change in National Institute of Health Stroke Scale and discharge destination.

RESULTS

Forty-nine subjects with a mean age 76 ± 16 years underwent thrombolysis, 21 were under the care of a stroke neurologist and 28 by a non-neurologist stroke physician. No symptomatic intracranial haemorrhages were observed. There was no difference in terms of door-to-needle time, proportion of individuals with haemorrhagic transformation, mortality or discharge destination between the two groups.

CONCLUSION

Due to the single-centre, observational nature of this study, the equivalent outcomes between those thrombolysed by a stroke neurologist versus those thrombolysed by a stroke physician must be interpreted with caution pending further studies. Nevertheless, in the current setting, no signal for harm has been detected. This study is unique as it is the first to our knowledge comparing outcomes between a neurologist and non-neurologist following thrombolysis.

Shifts in the interpretation of health advocacy: a textual analysis

CONTEXT

Health advocacy is widely accepted as a key element of competency-based education. We examined shifts in the language and description of the role of the health advocate and what these reveal about its interpretation and enactment within the context of medical education.

METHODS

We conducted a textual analysis of three key documents that provide sequential depictions of the role of the health advocate in medical education frameworks: Educating Future Physicians for Ontario (1993), CanMEDS 2000 and CanMEDS 2005. We used a series of questions to examine shifts in the emphasis, focus and application of the role between documents. Theoretically, we drew upon Carlisle's conceptual framework to identify different approaches to advocacy.

RESULTS

We identified three major shifts in the language associated with the role of health advocate across our textual documents. Firstly, activities and behaviours that were initially positioned as being the responsibility of the profession as a whole came to be described instead as competencies required of every physician. Secondly, the initial focus on health advocacy as representing collective action towards public policy and systems-level change was altered to a primary focus on individual patients and doctors. Thirdly, we observed a progression away from descriptions of concrete actions and behaviours.

CONCLUSIONS

This study uncovers shifts in the language of physician advocacy that affect the discourse of health advocacy and expectations placed on physicians and trainees. Being explicit about expectations of the medical profession and individual practitioners may require renewed examination of societal needs. Although this study uses the CanMEDS role of Health Advocate as a specific example, it has implications for the conceptualisation of health advocacy in medicine and medical education globally.

The 'missing person' in roles-based competency models: a historical, cross-national, contrastive case study

CONTEXT

The use of roles such as medical expert, advocate or communicator to define competencies is currently popular in health professions education. CanMEDS is one framework that has been subject to great uptake across multiple countries and professions. The examination of the historical and cultural choices of names for roles generates insight into the nature and construction of roles. One role that has appeared in and disappeared from roles-based frameworks is that of the 'person'.

METHODS

In order to examine the implications of explicitly including or excluding the role of the 'physician as person' in a competency framework, we conducted a contrastive analysis of the development of frameworks in Canada and the Netherlands. We drew upon critical social science theoretical understandings of the power of language in our analysis.

RESULTS

In Canada, the 'person' role was a late addition to the precursory work that informed CanMEDS, and was then excluded from the final set of CanMEDS role names. In the Netherlands, a 'reflector' role was added in some Dutch schools and programmes when CanMEDS was adopted. This was done in order to explicitly emphasise the importance of the 'person' of the trainee.

CONCLUSIONS

In analysing choices of names for roles, we have the opportunity to see how cultural and historical contexts affect conceptions of the roles of doctors. The taking up and discarding of the 'person' role in Canada and the Netherlands suggest that as medical educators we may need to further consider the ways in which we wish the trainee as a person to be made visible in the curriculum and in assessment tools.

The 'missing person' in roles-based competency models: a historical, cross-national, contrastive case study

CONTEXT

The use of roles such as medical expert, advocate or communicator to define competencies is currently popular in health professions education. CanMEDS is one framework that has been subject to great uptake across multiple countries and professions. The examination of the historical and cultural choices of names for roles generates insight into the nature and construction of roles. One role that has appeared in and disappeared from roles-based frameworks is that of the 'person'.

METHODS

In order to examine the implications of explicitly including or excluding the role of the 'physician as person' in a competency framework, we conducted a contrastive analysis of the development of frameworks in Canada and the Netherlands. We drew upon critical social science theoretical understandings of the power of language in our analysis.

RESULTS

In Canada, the 'person' role was a late addition to the precursory work that informed CanMEDS, and was then excluded from the final set of CanMEDS role names. In the Netherlands, a 'reflector' role was added in some Dutch schools and programmes when CanMEDS was adopted. This was done in order to explicitly emphasise the importance of the 'person' of the trainee.

CONCLUSIONS

In analysing choices of names for roles, we have the opportunity to see how cultural and historical contexts affect conceptions of the roles of doctors. The taking up and discarding of the 'person' role in Canada and the Netherlands suggest that as medical educators we may need to further consider the ways in which we wish the trainee as a person to be made visible in the curriculum and in assessment tools.

Medical education... meet Michel Foucault

CONTEXT

There have been repeated calls for the greater use of conceptual frameworks and of theory in medical education. Although it is familiar to few medical educators, Michel Foucault's work is a helpful theoretical and methodological source.

METHODS

This article explores what it means to use a 'Foucauldian approach', presents a sample of Foucault's historical-genealogical studies that are relevant to medical education, and introduces the work of four researchers currently undertaking Foucauldian-inspired medical education research.

RESULTS

Although they are not without controversy, Foucauldian approaches are employed by an increasing number of scholars and are helpful in shedding light on what it is possible to think, say and be in medical education.

CONCLUSIONS

Our hope in sharing this Foucauldian work and perspective is that we might stimulate a dialogue that is forward-looking and optimistic about the possibilities for change in medical education.

Compassionate care? A critical discourse analysis of accreditation standards

CONTEXT

We rely upon formal accreditation and curricular standards to articulate the priorities of professional training. The language used in standards affords value to certain constructs and makes others less apparent. Leveraging standards can be a useful way for educators to incorporate certain elements into training. This research was designed to look for ways to embed the teaching and practice of compassionate care into Canadian family medicine residency training.

METHODS

We conducted a Foucauldian critical discourse analysis of compassionate care in recent formal family medicine residency training documents. Critical discourse analysis is premised on the notion that language is connected to practices and to what is accorded value and power. We assembled an archive of texts and examined them to analyse how compassionate care is constructed, how notions of compassionate care relate to other key ideas in the texts, and the implications of these framings.

RESULTS

There were very few words, metaphors or statements that related to concepts of compassionate care in our archive. Even potential proxies, notably the doctor-patient relationship and patient-centred care, were not primarily depicted in ways that linked them to ideas of compassion or caring. There was a reduction in language related to compassionate care in the 2013 standards compared with the standards published in 2006.

CONCLUSIONS

Our research revealed negative findings and a relative absence of the construct of compassionate care in our archival documents. This work demonstrates how a shift in curricular focus can have the unintended consequence of making values that are taken for granted less visible. Given that standards shape training, we must pay attention not only to what we include, but also to what we leave out of formal documents. We risk losing important professional values from training programmes if they are not explicitly highlighted in our standards.

Do not forget the oldest old: design principles for the 80+

A significant amount of research has been conducted regarding the design of Internet applications for the elderly. Concomitantly, researchers have been applying online technologies to healthcare for older adults. The oldest old (for our purposes, defined as older adults aged 80+) are increasingly adopting the use of the Internet and likely have different needs than those who are between 55 and 80 years old. The main results from a literature review on the existing research in human factors and design for older adults is presented. These results highlight the need for more research in human factors and design in the much neglected population group, the oldest old.

The practicality of theory

The study of medical education has broadened significantly over the past decade to include a wide variety of theoretical frameworks from multiple research domains. There remains a significant misconception, however, that learning theories (largely drawn from cognitive psychology and education) are practical and useful to educators, whereas other types of theory are not. The authors of this commentary reflect on a learning-theory-based model for developing master learners presented by Schumacher and colleagues in this issue of Academic Medicine. They suggest that bioscientific and sociocultural theories can enhance different aspects of that model and provide specific examples from neuropsychophysiology, Foucauldian discourse analysis, and critical theory. Bioscientific and sociocultural theories such as these present medical educators with an exciting array of new methodological and interpretive possibilities. The authors illustrate ways in which these theories can have important practical applications for, and impacts on, the practice of medical education.

Laying the foundation: teaching policy and advocacy to medical trainees

BACKGROUND

A novel and comprehensive two-year health policy curriculum was developed and implemented for family medicine residents at two University of Toronto-affiliated teaching sites.

AIM

To evaluate the impact of the curriculum on residents' knowledge of health policy issues, and its usefulness to their learning.

METHOD

The evaluation included a pre-post delivery assessment of residents' content-based knowledge of issues in the Canadian healthcare system. Residents were also asked to evaluate the content, process and usefulness of the health policy curriculum.

RESULTS

At the end, more than two-thirds of residents had a better understanding of the Canadian healthcare system. The overall pre-post scores showed that residents retained content-based facts in some detail. However, more importantly, residents' positive evaluations of the curriculum indicated they were engaged, enthusiastic and recognized its importance for their learning.

CONCLUSION

Despite residents' positive evaluations, questions remain as to how best to assess the success of health policy curricula. Moving beyond the popular pre-post test, less traditional approaches might complement standard program evaluation methods in future. As educators increasingly develop curricula aimed at non-biomedical expertise, we must consider how we can most meaningfully evaluate long-term impact on graduates' approach to clinical practice and their engagement in health system advocacy.

Physician, healthy system: the challenge of training doctor-citizens

The need for committed "doctor-citizens" engaged in health system improvement has led to a variety of medical curricular overhauls in North America and elsewhere. In a research paper published in this edition, we evaluated one such curriculum and found it to be modestly successful. But, what are the limits of residency curriculum in producing such doctors? Much of the culture of medical practice runs against the grain of our efforts. In this piece we reflect on broader lessons learned in the process of trying to teach health policy and advocacy to family medicine residents.

Scientist or science-stuffed? Discourses of science in North American medical education

CONTEXT

The dominance of biomedical science in medical education has been contested throughout the past century, with recurring calls for more social science and humanities content. The centrality of biomedicine is frequently traced back to Abraham Flexner's 1910 report, 'Medical Education in the United States and Canada'. However, Flexner advocated for a scientist-doctor, rather than a curriculum filled with science content. Examination of the discourses of science since Flexner allows us to explore the place of various knowledge forms in medical education.

METHODS

A Foucauldian critical discourse analysis was performed, examining the discourses of scientific medicine in Flexner's works and North American medical education articles in subsequent decades. Foucault's methodological principles were used to identify statements, keywords and metaphors that emerged in the development of the discourses of scientific medicine, with particular attention to recurring arguments and shifts in the meaning and use of terms.

RESULTS

Flexner's scientist-doctor was an incisive thinker who drew upon multiple forms of knowledge. In the post-Flexner medical education reforms, the perception of science as a discursive object embedded in the curriculum became predominant over that of the scientist as the discursive subject who uses science. Science was then considered core curricular content and was discursively framed as impossibly vast. A parallel discourse, one of the insufficiency of biomedical science for the proper training of doctors, has existed over the past century, even as the humanities and social sciences have remained on the margins in medical school curricula.

CONCLUSIONS

That discourses of scientific medicine have reinforced the centrality of biomedicine in medical education helps to explain the persistent marginalisation of other important knowledge domains. Medical educators need to be aware of the effects of these discourses on understandings of medical knowledge, particularly when contemplating curricular reform.

Looking back to move forward: using history, discourse and text in medical education research: AMEE guide no. 73

As medical education research continues to diversify methodologically and theoretically, medical education researchers have been increasingly willing to challenge taken-for-granted assumptions about the form, content and function of medical education. In this AMEE guide we describe historical, discourse and text analysis approaches that can help researchers and educators question the inevitability of things that are currently seen as 'natural'. Why is such questioning important? By articulating our assumptions and interrogating the 'naturalness' of the status quo, one can then begin to ask why things are the way they are. Researchers can, for example, ask whether the models of medical education organization and delivery that currently seem 'natural' to them have been developed in order to provide the most benefit to students or patients--or whether they have, rather, been developed in ways that provide power to faculty members, medical schools or the medical profession as a whole. An understanding of the interplay of practices and power is a valuable tool for opening up the field to new possibilities for better medical education. The recognition that our current models, rather than being 'natural', were created in particular historical contexts for any number of contingent reasons leads inexorably to the possibility of change. For if our current ways of doing things are not, in fact, inevitable, not only can they be questioned, they can be made better; they can changed in ways that are attentive to whom they benefit, are congruent with our current beliefs about best practice and may lead to the production of better doctors.

Competency-based education in family medicine

BACKGROUND

As a way of demonstrating an objective assessment of trainee competence, the College of Family Physicians of Canada has recently approved a competency-based framework known as CanMEDS-FM. All training programs in family medicine in Canada will be required to demonstrate the development of curriculum and evaluation methods based on the roles defined by the framework.

AIM

This article describes the rationale and the approach used to develop a competency-based education curriculum in the postgraduate family medicine program at the University of Toronto.

METHOD

The authors describe a systematic approach to curriculum development which includes the formation of a central steering committee, content development by faculty experts, mapping of curriculum to an accreditation framework, and a faculty consensus exercise. We discuss challenges to development and implementation of a competency-based framework as well as areas that require further work and development.

CONCLUSIONS

The competency-based curriculum is both a new method of learning for residents and, a new method of teaching for faculty. While there are many potential benefits and challenges, this article focuses on the model's utility in terms of flexible learner-centered educational design, as well as its ability to identify learners' strengths and needs.

New Delhi metallo-β-lactamase-1: local acquisition in Ontario, Canada, and challenges in detection

New Delhi metallo-β-lactamase-1 (NDM-1) is a recently identified metallo-β-lactamase that confers resistance to carbapenems and all other β-lactam antibiotics, with the exception of aztreonam. NDM-1 is also associated with resistance to many other classes of antibiotics. The enzyme was first identified in organisms isolated from a patient in Sweden who had previously received medical treatment in India, but it is now recognized as endemic throughout India and Pakistan and has spread worldwide. The gene encoding NDM-1 has been found predominantly in Escherichia coli and Klebsiella pneumoniae. We describe the isolation NDM-1-producing organisms from two patients in Toronto, Ontario. To the best of our knowledge, this is the first report of an organism producing NDM-1 that was locally acquired in Canada. We also discuss the evidence that NDM-1 can affect bacterial species other than E. coli and K. pneumoniae, the limited options for treatment and the difficulty laboratories face in detecting organisms that produce NDM-1.