An evaluation of a new practice-based small group learning (PBSGL) initiative in Wales

In 2018, a new practice-based small group learning (PBSGL) pilot initiative was launched in Wales to promote interprofessional learning among different primary care professionals. The aim of this study was to evaluate the initiative in order to identify its strengths and areas for improvement. Data were collected through focus groups with PBSGL groups in Wales and analysed thematically. Participants generally held positive views of PBSGL and were impressed with the variety and overall relevance of the learning materials, although concern was raised about the relevance of all learning materials to the Welsh context. The interprofessional component was valued for reducing feelings of isolation and all participants were able to contribute to discussions, an outcome helped by existing relationships among group members. Many participants reflected on occasions where they had made changes to their practice as a result of PBSGL activity. Time and funding were cited as potential barriers to continuing participation in PBSGL and there is scope to tailor material more to the context of the healthcare system in Wales.

Disciplinary boundaries and integrating care: using Q-methodology to understand trainee views on being a good doctor

BACKGROUND

Rising numbers of patients with multiple-conditions and complex care needs mean that it is increasingly important for doctors from different specialty areas to work together, alongside other members of the multi-disciplinary team, to provide patient centred care. However, intra-professional boundaries and silos within the medical profession may challenge holistic approaches to patient care.

METHODS

We used Q methodology to examine how postgraduate trainees (n = 38) on a range of different specialty programmes in England and Wales could be grouped based on their rankings of 40 statements about 'being a good doctor'. Themes covered in the Q-set include: generalism (breadth) and specialism (depth), interdisciplinarity and multidisciplinary team working, patient-centredness, and managing complex care needs.

RESULTS

A by-person factor analysis enabled us to map distinct perspectives within our participant group (P-set). Despite high levels of overall commonality, three groups of trainees emerged, each with a clear perspective on being a good doctor. We describe the first group as 'generalists': team-players with a collegial and patient-centred approach to their role. The second group of 'general specialists' aspired to be specialists but with a generalist and patient-centred approach to care within their specialty area. Both these two groups can be contrasted to those in the third 'specialist' group, who had a more singular focus on how their specialty can help the patient.

CONCLUSIONS

Whilst distinct, the priorities and values of trainees in this study share some important aspects. The results of our Q-sort analysis suggest that it may be helpful to understand the relationship between generalism and specialism as less of a dichotomy and more of a continuum that transcends primary and secondary care settings. A nuanced understanding of trainee views on being a good doctor, across different specialties, may help us to bridge gaps and foster interdisciplinary working.

Developing educators of European undergraduate dental students: Towards an agreed curriculum

INTRODUCTION

Recent developments in European dental education are student-focused, concerned with competency-based and problem-based learning. The development of dental educators has so far received little consideration. This study aimed to agree curriculum content for developing dental educators so that they are better able to support changing undergraduate dental education.

METHODS

Adopting consensus methodology, a 2-round Delphi was conducted in 2012. Fifty-three dental educators and 39 dental students across Europe volunteered to take part. The Delphi questionnaire was developed based on literature, piloted and sent to participants to gather opinions and seek consensus on educational content using rating scales and open-ended questions. Numeric data were analysed using descriptive statistics, and qualitative data were analysed thematically.

RESULTS AND DISCUSSION

This study revealed 7 domains of curriculum content for dental educators. Four of these domains were considered essential: educational principles; educational practice in dentistry; curriculum, quality and improvement; and educational professionalism. Three domains were viewed as optional and could be tailored to local needs: educational principles in relation to specific contexts, educational research, and educational and healthcare management. When developing training for dental educators, factors which need consideration were identified as the academic position and teaching experience of educators, and the nature of clinical dental education.

CONCLUSION

The results are beneficial for individual educators to inform professional development plans; institutions to devise faculty developments; ADEE to inform policies on developing European dental educators; and other disciplines to inform training for their educators.

Competence, competency-based education, and undergraduate dental education: a discussion paper

INTRODUCTION

The aim of undergraduate dental education is to provide competent dentists to serve societal needs and improve population oral healthcare. Competency-based education has influenced the development of dental education for decades but this term is problematic. This article explores components of competency-based undergraduate health professional education in order to help the dental profession have a better understanding of the context and purposes of undergraduate dental education.

METHODS

This is a discussion paper based on a wide reading of the literature on the education of health professionals with a specific focus on competency-based undergraduate education.

RESULTS AND DISCUSSION

Competence comprises an integration of knowledge, skills and attitudes indicating a capability to perform professional tasks safely and ethically. The process of becoming a competent practitioner is complex. Four characteristics of competency-based education are: curriculum components and content shaped by societal needs; focused on student-centred learning; learning achievement; and limited attention to time-based training and numerical targets. Alongside a competency-based approach, undergraduate dental education can be influenced by institutional features and external factors but these receive little consideration in the literature.

CONCLUSION

Understanding competence, competency-based education, and institutional and external factors will help to improve educational quality, define roles and professional development for the dental educator, and inform further research.

'It's surprising how differently they treat you': a qualitative analysis of trainee reflections on a new programme for generalist doctors

OBJECTIVES

An increase in patients with long-term conditions and complex care needs presents new challenges to healthcare providers around the developed world. In response, more broad-based training programmes have developed to better prepare trainees for the changing landscape of healthcare delivery. This paper focuses on qualitative elements of a longitudinal, mixed-methods evaluation of the postgraduate, post-Foundation Broad-Based Training (BBT) programme in England. It aims to provide a qualitative analysis of trainees' evaluations of whether the programme meets its intentions to develop practitioners adept at managing complex cases, patient focused care, specialty integration and conviction in career choice. We also identify unintended consequences.

SETTING

9 focus groups of BBT trainees were held over a 12-month period. Discussions were audio-recorded and subjected to directed content analysis. Data were collected from trainees across all 7 participating regions: East Midlands; West Midlands; Severn; Northern; North Western; Yorkshire and Humber; Kent, Surry and Sussex.

PARTICIPANTS

Focus group participants (61 in total) from the first and second cohorts of BBT.

RESULTS

Evidence from trainees indicated that the programme was meeting its aims: trainees valued the extra time to decide on their onward career specialty, having a wider experience and developing a more integrated perspective. They thought of themselves as different and perceived that others they worked alongside also saw them as different. Being different meant benefitting from novel training experiences and opportunities for self-development. However, unintended consequences were feelings of isolation, and uncertainty about professional identity.

CONCLUSIONS

By spanning boundaries between specialties, trainee generalists have the potential to improve experiences and outcomes for patients with complex health needs. However, the sense of isolation will inhibit this potential. We employ the concept of 'belongingness' to identify challenges related to the implementation of generalist training programmes within existing structures of healthcare provision.

Communication and professionalism skills of a new graduate: the expectations and experiences of dental foundation trainers

AIM

The aim of this study was to investigate dental foundation year 1 (DF1) trainers' expectations of the dental graduate specifically in relation to non-clinical (professionalism and communication) skills and to explore whether these expectations were being met.

METHOD

In the UK, dental graduates undertake 1 year of foundation training prior to being permitted to undertake NHS practice. An online survey was distributed to DF1 trainers via all 11 English deaneries and the Northern Ireland deanery. Demographic information and a general view of trainers' expectations of a new trainee were collected. Specific questions relating to six generic trainee problems were followed by 11 ability statements where trainers indicated their expectation of a trainee's ability to perform the skill on a 5-point scale (on own with confidence-unable to undertake). Statements were repeated and trainers were required to respond using the same scale in relation to experience of their current trainee.

RESULTS

Five hundred and ten (53%) trainers completed the questionnaire with no missing data. Expectations were high with almost 50% of trainers expecting a new graduate to manage a full list of patients on their own. Experience of new graduates did not always match these expectations. Of concern was the ability to 'keep accurate patient records' and 'self-reflection and knowing when to seek help', where a small proportion of trainers experienced difficulties.

CONCLUSIONS

Trainers' expectation and experience in relation to non-clinical skills of a new graduate were investigated. Although they had high expectations, the majority reported only minor problems overall. There were a few areas where concern was raised.

A review of continuing professional development for dentists in Europe(*)

AIM

  To summarise findings from a literature review of dentists' engagement in continuing professional development (CPD) and its effects on improving oral health care for patients.

METHOD

  The search strategy used key terms in a range of databases and an academic literature search engine, complemented by hand searching and citation follow-up.

RESULTS

  One hundred and fourteen papers were reviewed. The majority of dentists engaged in CPD. Factors affecting participation included time since graduation, costs, work and home commitments, postgraduate qualification, interest and convenience. Learning needs identification and reflection on practice were rarely evidenced. Common modes of CPD were courses and journal reading; no one delivery method proved more effective. Few papers directly explored recommendations for topics although suggestions related to common areas of error and gaps in knowledge or skill. Studies of CPD effectiveness and impact-on-practice suggested that courses can result in widespread new learning and considerable self-reported change in practice. However, significant barriers to implementing change in workplace practice were noted and included availability of materials, resources and support from colleagues.

CONCLUSION

  To ensure high standards of care, alongside recommending core or mandatory topics, more attention should be given to reflection on learning needs, the learner's readiness to engage with education and training and the influence of the workplace environment.

An evaluation of CPD activity of dentists in Wales

INTRODUCTION

Ongoing professional education is essential for dental professionals to maintain and update their clinical skills and knowledge. There is a current trend towards mandatory Continuing Professional Development (CPD) for dentists within Europe and beyond. Mandatory CPD will ensure high professional standards and enable mobilisation of the dental workforce within Europe. In 2002, the UK General Dental Council (GDC) implemented a system of mandatory CPD for dentists practicing in the UK. The Wales Deanery is situated in the School of Postgraduate Medical and Dental Education, Cardiff University. It provides verifiable CPD courses for dentists and dental care professionals (DCPs) currently practicing in Wales and has recorded professionals' attendance on these courses since 2001. The project aimed to investigate the CPD activity of dentists in Wales, using these data.

METHODS

The Wales Deanery database holds data on the CPD courses undertaken by 1178 dentists working in Wales since 2001. A number of hypotheses were investigated using a variety of statistical methods.

RESULTS

Dentists were undertaking significantly fewer hours of CPD in Mid and West Wales compared to the North and South of the principality. Sole practitioners were found to engage in less CPD than those in group practices, but these differences did not reach statistical significance. Dentists who employed a hygienist or therapist completed more hours of CPD than those who didn't employ either. There were no gender differences in engagement in CPD. CPD participation was consistently and significantly higher in mid and late career than in early career.

CONCLUSIONS

This study provides a greater understanding of the CPD habits of the dental workforce in Wales. Practice staffing levels, location of practice and time since graduation were found to have the greatest impact on engagement in CPD activity. These findings will be used by the Deanery to inform future education provision for dental professionals in Wales.

A review of continuing professional development for dentists in Europe

AIM

To summarise findings from a literature review of dentists' engagement in continuing professional development (CPD) and its effects on improving oral health care for patients.

METHOD

The search strategy used key terms in a range of databases and an academic literature search engine, complemented by hand searching and citation follow-up.

RESULTS

One hundred and fourteen papers were reviewed. The majority of dentists engaged in CPD. Factors affecting participation included time since graduation, costs, work and home commitments, postgraduate qualification, interest and convenience. Learning needs identification and reflection on practice were rarely evidenced. Common modes of CPD were courses and journal reading; no one delivery method proved more effective. Few papers directly explored recommendations for topics although suggestions related to common areas of error and gaps in knowledge or skill. Studies of CPD effectiveness and impact-on-practice suggested that courses can result in widespread new learning and considerable self-reported change in practice. However, significant barriers to implementing change in workplace practice were noted and included availability of materials, resources and support from colleagues.

CONCLUSION

To ensure high standards of care, alongside recommending core or mandatory topics, more attention should be given to reflection on learning needs, the learner's readiness to engage with education and training and the influence of the workplace environment.

Continuing dental education: evaluation of the effectiveness of a disinfection and decontamination course

AIM

To evaluate a disinfection and decontamination dental postgraduate course run by the Wales Dental Postgraduate Deanery between 2008 and 2010.

METHODS

Pre- and post-course multiple choice questionnaires were completed by 1177 course attendees. Mean scores before and after participation on the training course were compared and analysed.

RESULTS

Mean pre-course score was 45.3%, rising to 87.0% in the post-course assessment, reflecting an improvement of 41.8%. Prior to training, 30.7% achieved a satisfactory score of 13/20 (65%) compared to 98.3% on completion of training. Dental technicians were found to score significantly lower than other occupation groups both before and after course attendance. Decade of graduation had no effect on results. Theoretical microbiology was the question area which showed least improvement.

CONCLUSION

Attending the disinfection and decontamination course significantly improved participants' knowledge. Theoretical microbiology, as a topic area, may be targeted for improvements in future courses to improve results further.

Supporting return to dentistry: a national evaluation of the Retaining and Returning Advisory Service

INTRODUCTION

Workforce concerns in National Health Service (NHS) dentistry have led to Government initiatives to strengthen recruitment and retention. This study (commissioned by the Department of Health, England) explored the role, uptake and user reaction to the new Retaining and Returning Advisory Service in dentistry operating in all 12 postgraduate deaneries in 2002.

METHOD

The primary focus of the evaluation study was the first year of the Retaining and Returning Advisory Service. All 12 Retaining and Returning Advisers (RRAs) were interviewed twice; all completed a record form for each one-to-one contact with users of the service (n = 217); and users' views were elicited through questionnaires (n = 82) and case study interviews (n = 10).

RESULTS

RRAs' key activities in the first 12 months were to raise awareness of their role and provide one-to-one support for users (n = 217). Some also organised courses for dentists out of practice. Most one-to-one contacts were with female dentists on career breaks and registered on the Keeping in Touch Scheme (KITS). Support included: (i) planning continuing education; (ii) advice on job applications and requirements; and (iii) general careers guidance. Users' feedback was positive: confidence was increased and they valued targeted, hands-on courses. Postgraduate Dental Deans have integrated RRAs into their wider activities.

CONCLUSION

The Retaining and Returning Advisory Service provided support to potentially vulnerable groups of dentists. The joint launch of the Retaining and Returning Advisory Service, the revised Keeping in Touch Scheme, and expanded availability of update courses created a comprehensive package of support.

Temporary registration in primary care for dentists moving to the UK from outside the EU: an evaluation of a national pilot scheme

INTRODUCTION

An evaluation of a pilot scheme offering temporary registration with the General Dental Council (GDC) for up to six months in primary care for overseas-qualified (non-EU) dentists studying for the International Qualifying Examination (IQE) Part C.

METHODS

In all five pilot sites dental attachments and supervisors were interviewed at the start (n = 10) in 2005. At six months, supervisors were interviewed again (n = 4), and dental attachments were surveyed (n = 5). Patient (n = 15) and staff (n = 27) views were elicited through questionnaires.

RESULTS

Hands-on clinical practice was the prime motive for involvement. Patient safety was safeguarded through close supervision of attachments' dental treatment. The value of clinical experience, development of patient management skills, work in a dental team, and familiarity of NHS procedures was highlighted. Feedback from patients and staff was positive: attachments' enthusiasm, approach, willingness to take responsibility, and follow protocols were rated highly. The National Advice Centre for Postgraduate Dental Education (NACPDE), England coordinated the pilot (including selection and matching of candidates to supervisors). They established good links with pilot sites and maintained training standards.

CONCLUSION

Temporary registration with the GDC provided valuable educational opportunities, specifically hands-on experience in primary care beneficial in preparing for IQE Part C. The evaluation demonstrated scope to consolidate the pilot and its expansion has been approved by the GDC.

Key skills for newly qualified dentists: an evaluation of a West Midlands initiative

INTRODUCTION

This paper reports an evaluation of the West Midlands Key Skills initiative that provides a framework for learning during vocational training (VT).

METHOD

The 48 vocational dental practitioners (VDPs) who began their VT in August 2001 in the West Midlands were surveyed at the start and end of training (45 completed both surveys). They rated their confidence and experience in the 31 components of the Six Key Skills on visual analogue scales. Views were elicited in a survey of both VDPs (47 returns) and their general practice trainers (44 returns). Semi-structured interviews were also held with a stratified sample of 9 trainers and all four VT advisors.

RESULTS

In terms of VDP progress, a statistically significant increase in confidence and experience was found in each of the 31 components. Six themes were identified in the views data. (i) Supporting the development of Key Skills; (ii) workload implications; (iii) the "right" six? (iv) links with the advanced diploma (MFGDP(UK)); (v) assessment of VT; and, (vi) consistency and quality assurance.

CONCLUSION

VT successfully develops the confidence and experience of newly qualified dentists in the Six Key Skills and has been well received by the majority of VDPs, trainers and advisors in the West Midlands.

The impact of course attendance on the practice of dentists

INTRODUCTION

This paper reports the impact of course attendance on the practice of dentists.

METHOD

Phase One: A survey sent to all general dental practitioners (GDPs) in three deaneries in England. The survey included self-ratings of the impact of course attendance on practice. Phase Two: Interviews with 20 dentists before and two to three months after they had participated in a self-selected course. The response rate to the survey was 54% (n = 2082). Comparisons with national data showed no notable bias in the sample for gender, owners/partners and age/experience. An ordered logit model was used to explore the net effect of factors (including years' experience in general dental practice and gender) on dentists' ratings of course impact.

RESULTS

Course attendance was judged to impact on practice. Impact rating was affected by participation rate and years' experience. Barriers to implementation included cost, time, NHS constraints and personal or staff issues. Impact was enhanced when selection of courses was based on learning needs although courses may also serve usefully to confirm current practice.

CONCLUSION

There is much that dentists themselves can do to enhance the impact of courses, principally by reflecting on learning needs. They should be supported in the development of personal learning plans.

The selection of GP trainees in the West Midlands: second audit of assessment centre scores by ethnicity and country of qualification

The new regional GP trainee selection process in the West Midlands aims to be fair, open and efficient in selecting the most suitable candidates for training posts. This paper is a follow-up audit of the results of the first selection round that have previously been published in this journal (Brown et al., 2001). Here we provide an analysis of candidates' performance in the selection process by ethnic background and country of qualification for the first four selection rounds (n=753). Performance is assessed in terms of the percentage of candidates passing the shortlist stage and being offered a training post in the West Midlands, and by an analysis of shortlist and total scores. This audit finds that UK-trained candidates are most likely to be shortlisted; African- and Asian-trained candidates are the least likely to be shortlisted; and Asian-trained candidates have relatively low success in being placed in the West Midlands.

Recommendations for improving the assessment of postgraduate dental education

This paper makes recommendations for the improvement of assessment in postgraduate dental education. The recommendations are based on a twelve-month study conducted in 1998/99 which evaluated the strengths and weaknesses of the existing assessment systems. Evidence was taken from examination syllabi, assessments and records. Semi-structured interviews were conducted with representatives from national bodies and with trainers and trainees in the West Midlands. Strengths in parts of the system include: commitment and professional experience; commissioned work; opportunity to share experience; a monitoring framework; procedures for maintaining standards and examples of broadbased assessments. Weaknesses include: lack of assessment of quality; existence of some forms of unregulated assessment; lack of transparency and lack of clarity between training and assessment. Development is recommended in three broad areas: a competence-based model of assessment; distinguishing assessment from the analysis of educational needs and quality assurance. The introduction of a competence-based model is the most significant and is addressed in some detail. Specific proposals for consideration by national regulatory bodies and education providers include: strengthening the management of assessment; national leadership in the development of a competence model of assessment; widening the assessment base; clearer criteria for inspection; revisions to how vocational training, HO/SHO training and general professional training are assessed and training for trainers.

The selection of GP trainees in the West Midlands: audit of assessment centre scores by ethnicity and country of qualification

The new regional, centralized system of selecting GP trainees in the West Midlands aims to be fair and non-discriminatory in the processes of recruiting the most suitable candidates and allocating the successful candidates to their preferred posts. This paper provides an audit of the achievements of all (n = 165) the candidates in the October 2000 selection round. Initial analysis suggests that gender is not a significant factor in determining outcomes. In this paper, the data are examined with respect to candidates' ethnic background and their country of qualification. Two levels of analysis are possible, based on average 'success' or placement rates, and average scores achieved at each stage of the selection process. The analysis, using one-sided significance tests, suggests that White candidates, and those qualifying in the UK, are more likely to succeed in the selection process. Possible explanations are offered from a more detailed interrogation of the selection criteria. Finally, the implications for the next selection round are discussed in the light of these findings.

Assessment in postgraduate dental education: an evaluation of strengths and weaknesses

This paper describes a study designed to evaluate assessment in postgraduate dental education in England, identifying strengths and weaknesses and focusing specifically on its relevance, consistency and cost-effectiveness.

METHODS

A four-phase qualitative method was used: a mapping of current career paths, assessment policy, and issues (phase 1); more detailed studies of the practice of assessment for a range of courses, and the systemic/management perspective of assessment (i.e. quality assurance) (phases 2 and 3), and analysis and reporting (phase 4). Data were analysed from documents, interviews, group consultations and observations.

RESULTS AND DISCUSSION

Five key issues may be distilled from the findings: (i) lack of formal assessment of general professional training; (ii) trainer variation in assessment; (iii) the extent to which assessments are appropriate indicators of later success; (iv) the relationship between assessment and patient care, and (v) data to assess the costs of assessment.

CONCLUSION

Current assessment procedures might be improved if consideration is given to: assessment which supports an integrated period of general professional training; training for trainers and inspection procedures to address variation; more authentic assessments, based directly on clinical work and grading cases and posts, and better data on allocation of resources, in particular clinicians' time given to assessment.

The benefits and costs of continuing professional development (CPD) for general dental practice: a discussion

This paper sets out the benefits and costs of continuing professional development (CPD) for general dental practice. These considerations are important in evaluating CPD yet they are rarely formally assessed. This paper draws on literature specifically on dentistry but also from across the medical profession and the economics of education and training. First, the costs of CPD are itemised with some suggestions as to how costs may be reduced. Second, the benefits are identified and the (limited) evidence on the value of CPD is surveyed. Finally, reasons why some GDPs might not undertake sufficient or appropriate CPD are explored and the need for guidance for dental practitioners is identified.

Testicular microlithiasis: US follow-up

PURPOSE

To determine in patients with testicular microlithiasis (TM) the short-term natural history of classic TM (CTM) and limited TM (LTM).

MATERIALS AND METHODS

In 104 patients, testicular microliths were identified on ultrasonographic (US) images; 39 patients had five or more microliths on at least one US image (criterion for CTM), and 65 patients had fewer than five microliths (criterion for LTM). Attempts were made to have all patients return for follow-up US to assess for change in TM or development of tumor.

RESULTS

Seven (18%) of the 39 patients with CTM and one (2%) of the 65 patients with LTM had tumor at presentation (P =.004). Among all 104 patients, follow-up US was performed in 72 patients (31 with CTM, 41 with LTM), with mean follow-up of 45 months (range, 12-90 months). None of these patients had interval development of testicular neoplasm. LTM did not progress to CTM in any patient. Progression in number of microliths was seen in two patients with CTM.

CONCLUSION

Patients with LTM have a lower prevalence of associated malignancy than do patients with CTM. The risk of developing malignancy in patients with isolated TM (LTM or CTM) is low at short-term follow-up. These results raise the question of the need for routine US in this patient population.

A role for clinical audit and peer review in the identification of continuing professional development needs for general dental practitioners: a discussion

The purpose of this paper is to discuss how the role of peer review and clinical audit may be used in the identification of the continuing professional development (CPD) needs of general dental practitioners (GDPs). Clinical audit and peer review are intrinsically valuable in terms of the continued professional development of GDPs. Collaborative clinical audit, in particular, can provide a framework for short course input and there are particular benefits to this combination of activities which might usefully be more widely encouraged. If open to analysis in a way which retains individual anonymity, peer review and clinical audit resumes, these could be used to inform the provision of CPD and, linked to the knowledge of audit facilitators, short courses might more closely match the CPD needs of local dentists.

A framework for the evaluation of continuing education short courses in dentistry

The objective of this paper is to propose an evaluation framework for short courses in continuing education for general dental practitioners (GDPs) (so called, Section 63 courses). Existing monitoring and evaluation procedures in the West Midlands deanery were examined and an improved evaluation framework was then devised, piloted and revised. A 5 phase method was used incorporating the examination of existing practice (Phases 1 and 2), development of a new framework (Phase 3), piloting (Phase 4) and revision of the evaluation framework in the light of the pilot. This approach will be implemented in the West Midlands and may be adapted for national use (Phase 5). It was found that existing monitoring and evaluation was inconsistent in prevalence and scope. Those involved in short courses were in favour of a more consistent and visible evaluation, including some assessment of impact-on-practice and cost-effectiveness. In conclusion, meaningful evaluation needs to include four key processes: data gathering; data analysis; dissemination and, action planning (reviewing provision in the light of the data analysis). Thus, this evaluation framework feeds into a quality development cycle designed to ensure high quality and relevant short course provision for general dental practitioners.

Continuing education courses in dentistry: assessing impact on practice

INTRODUCTION

In the context of movement towards mandatory continuing dental education, this paper describes how a delayed postal questionnaire can be used in course evaluation. Specifically, the value of the questionnaire as a tool for assessing the impact of short course attendance on general dental practice is examined.

METHOD

Questionnaires were distributed to all those attending three courses, ranging in size, in the West Midlands region. As well as reflecting on the course, respondents were asked their views on the usefulness of the questionnaire, the length of time between course attendance and assessment of impact, and types of courses likely to have greatest impact.

RESULTS

Respondents thought the questionnaire an appropriate tool for assessing impact on practice, that an appropriate interval of time between the course and the delayed questionnaire is about six weeks, and that courses most likely to impact on practice are those which offer updates on common clinical topics and are hands-on in nature.

DISCUSSION

A delayed questionnaire could be a useful mechanism for evaluating the impact on practice of some types of courses. Response rates from those attending large lecture courses might be low. Course evaluation is also limited by resources and time. Criteria for identifying which courses should be subject to such evaluation might include high cost per participant and links with review cycles.

CONCLUSION

There is scope for more structured evaluation of continuing dental education, including the assessment of impact on practice. The questionnaire described is a useful component of an evaluation framework.

Use of lower prostate specific antigen cutoffs for prostate cancer screening in black and white men

PURPOSE

We evaluated differences in the prostate cancer detection rate among black and white men with serum prostate specific antigen (PSA) levels between 2.6 and 4.0 ng./ml., and benign findings on digital rectal examination.

MATERIALS AND METHODS

From May 1995 through June 1997 we screened 14,209 white and 1,004 black men 50 years old or older with serum PSA and rectal examinations at 6-month intervals. If PSA was greater than 2.5 ng./ml. or the rectal examination was suspicious for cancer, we recommended an ultrasound guided sextant biopsy of the prostate. We compared differences in clinical characteristics, compliance with the recommendation for biopsy, cancer detection rate, and stage and grade of tumors detected for 924 white and 57 black men.

RESULTS

Black men were younger (60 versus 63 years old, p = 0.005) and presented with slightly higher PSA levels (3.3 versus 3.1 ng./ml., p = 0.03) than white men. Overall cancer detection rate was 27% (106 of 391 patients), with cancer detection 2-fold higher among black (13 of 29, 45%) than among white (93 of 362, 26%) men (p = 0.03, odds ratio 2.4, 95% confidence interval 1.1 to 5.1). Controlling for age, total PSA, PSA density, percent free PSA and number of prior screening visits, race remained a significant predictor of cancer (adjusted odds ratio 3.4, confidence interval 1.4 to 8.4). We found trends for worse pathological stage and grade among black men but these differences did not reach statistical significance.

CONCLUSIONS

Black race was an independent predictor of prostate cancer even at lower PSA cutoffs (2.6 to 4.0 ng./ml.). Although the positive predictive value for cancer detection was relatively high in black men, long-term outcomes studies are necessary to determine whether the use of lower PSA cutoffs would result in favorable shifts in cancer stage and grade, and a reduction in racial differences in prostate cancer mortality rates.

Racial differences in operating characteristics of prostate cancer screening tests

PURPOSE

We evaluated racial differences in the operating characteristics of prostate specific antigen (PSA) and digital rectal examination as screening tests for early detection of prostate cancer.

MATERIALS AND METHODS

We screened 18,527 white and 949 black men 50 years old or older using serum PSA measurement and digital rectal examination. We recommended biopsies if either test was suspicious for cancer. For PSA greater than 4.0 ng./ml. and rectal examination we calculated relative sensitivity (percentage of men with cancer who had a positive test), specificity (percentage of men without cancer who had a negative test) and positive predictive value (percentage of men with a positive test in whom cancer was detected) for the prediction of prostate cancer stratified by race.

RESULTS

In white and black men PSA greater than 4.0 ng./ml. detected more cancers than rectal examination (p < 0.002) with a trend for a greater increase in sensitivity in black men. PSA was associated with fewer false-positives than rectal examination in white (p < 0.0001) but not in black (p > 0.05) men. Positive predictive value for prostate cancer of PSA and rectal examination was greater in black than in white men (48 versus 34 and 38 versus 22%, respectively).

CONCLUSIONS

PSA detects more cancers than rectal examination in both races, although this advantage is more pronounced in black men. In white men PSA yielded fewer false-positive results than rectal examination. However, PSA had more false-positive results than rectal examination in black men. Cancer was detected in a higher percentage of black men with PSA greater than 4.0 ng./ml. and, therefore, the risk of cancer associated with PSA greater than 4.0 ng./ml. differs by race. In a screening setting the widely accepted 25 to 30% positive predictive value for PSA greater than 4.0 ng./ml. may only apply to white men. A higher risk estimate of 36 to 60% is more accurate in black men.

Racial differences in a prostate cancer screening study

PURPOSE

We attempted to determine whether black men have a higher prostate cancer prevalence and more advanced disease.

MATERIALS AND METHODS

We screened 17,157 white and 804 black men 50 years old or older by serum prostate specific antigen measurement and digital rectal examination. We recommended biopsy when either test was suspicious.

RESULTS

Black men had a higher prevalence of elevated prostate specific antigen (13.1 versus 8.9%) and cancer (5.1 versus 3.2%) than white men, and a higher prevalence of clinically but not pathologically advanced cancer. Fewer black men in lower income zip codes complied with recommendations for biopsy.

CONCLUSIONS

In our screening study black men had a higher prevalence of detectable cancer. However, unlike in clinical studies there was no striking racial difference in advanced cancer stage at diagnosis.

Delayed infection of a pelvic lymphocele following pelvic lymphadenectomy

Pelvic lymphocele is an infrequent complication of pelvic surgery, usually presenting shortly after surgery. We report a case of an infected pelvic lymphocele presenting more than 1 year after a staging pelvic lymphadenectomy for adenocarcinoma of the prostate. This case illustrates that late infection of pelvic lymphoceles can occur following a pelvic lymphadenectomy and radical prostatectomy.

Fascial closure of laparoscopic port sites: a new technique

The laparoscopic operative procedure is not complete until the port sites are closed with a fascial suture. Herein, we report a simple new technique that uses a venous catheter for suture placement and direct laparoscopic visualization to secure the abdominal wall fascia and peritoneum.

Experimental autoimmune cystitis: a potential murine model for ulcerative interstitial cystitis

Interstitial cystitis is an inflammatory disease of unknown etiology. To facilitate the study of the pathophysiology of interstitial cystitis, an animal model that correlates with the clinical features of interstitial cystitis and expresses histologic features consistent with those observed in interstitial cystitis patients was developed. Various strains of mice were immunized with a syngeneic bladder homogenate to determine their susceptibility to the induction of autoimmune cystitis. Of 3 mouse strains tested, only the Balb/cAN mice reproducibly developed the clinical correlates and histological features consistent with those observed in interstitial cystitis. In a blinded pathologic review, autoreactive Balb/cAN bladders were correctly distinguished from chronic bacterial cystitis, sham treated bladders and normal control bladders. Edema, fibrosis, perivascular lymphocytic infiltrations and detrusor mast cell accumulation were apparent in 75% of the Balb/cAN mice 2 weeks after immunization and 100% at 4 weeks. These histologic features plateaued and remained stable for at least 6 months. Grossly, the immunized mouse bladders were fibrotic and contracted with a significantly (p < .05) decreased fluid capacity. On hydrodistension, increased vascular prominence and petechial hemorrhage (glomerulations) were evident. Instillation of 14C-urea demonstrated increased permeability in immunized bladders compared with controls. A cellular autoimmune basis for the cystitis is supported by adoptive transfer studies. Spleen cells from experimental mice but not controls transferred the histological features of the disease to naive mice. These studies outline the development of a new experimental autoimmune cystitis model that expresses features similar to those frequently observed in human interstitial cystitis, and may provide a model for the study of the inflammatory process associated with interstitial cystitis. Furthermore, these data suggest a possible role for cellular immune components in interstitial cystitis.