Internal medicine residents' acceptance of self-directed learning plans at the point of care

OBJECTIVES

We implemented a curriculum using self-directed learning plans (SDLPs) based on clinical questions arising from the residents' practice, and we report on perceptions and attitudes from residents in internal medicine regarding the use of SDLPs conceived at point of care.

METHODS

Internal medicine residents at a single community hospital in the Midwest were surveyed in 2006 regarding SDLPs. We report their perceived effectiveness in identifying knowledge gaps, the processes used to fill those gaps, and the resident outcomes using descriptive statistics.

RESULTS

A total of 26 out of 37 residents (70%) responded. Most (24 of 26; 92%) perceived SDLPs helped them to identify and fill knowledge gaps and that their skills in framing questions (23 of 26; 88%), identifying resources (21 of 26; 81%), and critically appraising the evidence (20 of 26; 77%) improved through regular use. They also felt these plans led to a meaningful change in their practice or provided further direction for learning (17 of 26; 65%). Most (21 of 26; 81%) reported their intent to include point-of-care learning in their continuing education after residency. We found no significant differences in the responses of first-year compared with second- or third-year residents.

CONCLUSIONS

Questions arising during patient care are strong motivators for physician self-directed learning. The residents' responses indicated that they accepted the SDLPs and intend to use them in practice. Embedding the discussion of the SDLPs in preclinic conferences has ensured sustainability during the past 5 years and has enabled us to demonstrate teaching of practice-based learning and improvement.

Credentialing physicians: challenges for continuing medical education

Professionals involved in the regulation, credentialing, and certification of physicians around the world met in Chicago in June 2000 to discuss systems to ensure the competence of physicians. We learned that public demand for evidence of continuing competence in practice is driving the profession in most countries to explore new approaches to the education and assessment of physicians. Most groups have called the value of traditional continuing medical education (CME) into question and are exploring the use of self-directed CME methods, self-assessment, and quality improvement as the main instruments for maintenance of certification. It seems likely that teachers will be required to integrate assessment with enhancement of competencies, in much the same way that a coach uses an athlete's performance as a basis for continuous improvement. Recognizing the tough challenges ahead and the demand for CME to adapt to complement future plans for continuous assessment of physician competence, conference participants agreed to create a communication network that would facilitate information sharing and avoid duplication of research efforts.

A catalyst for change in communication skills: the Canadian Breast Cancer Initiative

A major focus of the Canadian Breast Cancer Initiative (CBCI) has been the development of the programming, partnerships and networks necessary to enhance communication skills within the physician-patient relationship. In this paper, the rationale for taking this approach and the scope of the activities that have been undertaken will be described, as well as the rationale for producing this series of papers. February has been chosen as the month of publication, as previous major activities of the CBCI in the area of physician-patient communication skills have been held in the month of February. It is hoped that February may become known as Communication Skills Month just as October is Breast Cancer Month: the gauntlet is thrown down to others to continue making February the month to reinforce the significance of physician-patient communication skills in the provision of quality health care.

Factors important in promoting mammography screening among Canadian women

Among women aged 50 to 69 years, regular screening by mammography in combination with clinical examination, can substantially decrease the morbidity and mortality associated with breast cancer by facilitating early detection. Unfortunately, many Canadian women are not screened in accordance with current guidelines. Research to date is based primarily on large surveys conducted in the United States and less is known about the relevance of specific barriers to mammography screening among Canadian women. Multivariate results from the 1994-95 National Population Health Survey (NPHS) indicate that younger (40-49) and older (70+) women, those who are socioeconomically disadvantaged, and minority women are least likely to report having had a mammogram. Conversely, women with positive health behaviours, high social support, and positive mental health attributes are more likely to participate in mammography screening. These findings are discussed in terms of the implications for developing successful intervention programs for Canadian women and for setting priorities for further research.

[Initial experience with the PCDiary: software for physicians for documenting and evaluating individual learning]

A computer diary was developed for physicians to create a portfolio of their self-directed learning. Each item of learning is recorded in the form of a question along with the stimulus, the learning resources used and the outcome planned for the learning. The records of 123 physicians which volunteered to use the diary were analyzed. Their response to the software, elicited by survey, is described. Items of learning were most often stimulated by scanning the literature and while seeking information to manage a patient. The physicians recorded their intent to change their practice as the outcome to learning most often when the learning was stimulated while managing a patient. One-half of the physicians reported that keeping the diary made them think about their patient care.

Determining priorities for family physician education in substance abuse by the use of a survey

As the initial stage in developing a curriculum to assist family physicians to diagnose and manage alcohol abuse in their practices, questionnaires were mailed to a selected group of family physicians. A total of 117 physicians (34%) completed the questionnaire. The majority of physicians (70.1%) reported that fewer than 10% of their caseload experienced alcohol-related problems. Most physicians (59.3%) did not use any of the standard diagnostic instruments but reported that screening and detection was the most challenging alcohol-related problem along with patient management. The questionnaire identified a number of areas that could be used in the development of educational strategies to increase the expertise of primary care physicians in the diagnosis and management of alcohol-related problems.

Presymptomatic diagnosis for neurofibromatosis 2 with chromosome 22 markers

Neurofibromatosis 2 (NF2) is a dominantly inherited disorder characterized by multiple tumors of the central nervous system, predominantly bilateral vestibular schwannomas. The gene for NF2 is located in the chromosomal region 22q12 between the loci D22S1 and D22S28. We have performed genetic linkage analysis on 13 NF2 families with a total of nine polymorphic DNA markers, including five which we have recently mapped to this region. Two loci, D22S32 and NEFH, are linked to the NF2 locus at 0% recombination (lod scores of 6.03 and 4.28, respectively). By multipoint linkage analysis, we assign the NF2 gene to an interval of 7 cM, between the loci D22S212 and D22S28. We have used this set of nine markers to construct chromosome 22 haplotypes for the 82 at-risk individuals in this pedigree set. It has been possible to determine, with a high degree of certainty, the carrier status of 70 (85%) of these at-risk individuals. Risk prediction was possible in every case where DNA was available from both parents. Fifty-three of the 70 (76%) informative individuals were assigned decreased risks of being carriers. The use of chromosome 22 probes for risk assessment should result in a greatly reduced number of individuals who require periodic screening for NF2.

"Academic" CME and the social contract

The term academic continuing medical education (CME) is defined and explored from the perspective of forces that have made its usage necessary. These forces include the new understandings of the place, impact, and scope of CME, and, in particular, the increasing entrepreneurial interests in the field, unrelated to the improvement of physicians' competence or performance, or to health care outcomes. In addition to principles of CME provision promulgated by the Accreditation Council of CME, and those of ethical CME providers, academic CME implies the critical appraisal of the providers' activities, the creation of new knowledge about how physicians learn and change, and the dissemination of information based on such knowledge. Finally, the nature of academic CME providers is discussed, and the potential role of CME in fostering the social contract between the medical professional and society is explored.

A breast-ovarian cancer susceptibility gene maps to chromosome 17q21

Nineteen North American Caucasian families that contain a minimum of four confirmed cases of breast or ovarian cancer have been studied. Four polymorphisms (cLB17.1, D17S579, D17S588, and D17S74), which span a region of approximately 15 cM on chromosome 17q12, were typed. Our data confirm the location of a dominant gene conferring susceptibility to breast and ovarian cancer (maximum lod = 9.78) and suggest that the breast-ovarian cancer syndrome is genetically heterogeneous. Two recombinants in one large family suggest that the breast-ovarian cancer locus lies between D17S588 and D17S579.

Multicultural issues in medical curriculum: implications for Canadian physicians

This descriptive study explored multicultural issues in medical education which should be included in the curricula of both the undergraduate and residency programs of the Faculty of Medicine, The University of Calgary. Face-to-face interviews were conducted with 21 male and female ethnic patients to determine their expectations of and experiences with the health care they had received in Canada. Telephone interviews were conducted with ten primary care physicians to determine their experiences of providing care to new immigrants from cultures other than their own. Content analyses and comparison of the two sets of interview data revealed barriers to satisfaction, diagnosis and treatment. Some barriers were perceived both by the physicians and the ethnic patients, e.g. language, and attitudes towards medical technology and treatment. Others were perceived just by the physicians, e.g. patients' belief in traditional practices. Still others were perceived just by the ethnic patient, e.g. perceived racial discrimination. Based on the data from the interviews, two simulated patients were developed and presented to the students of medicine, both undergraduate and resident, to teach them about multicultural health care. This study demonstrates how local data about multicultural health issues can be used to develop simulated patients for inclusion in the medical curriculum.

Neurofibromatosis type 2 appears to be a genetically homogeneous disease

Neurofibromatosis type 2 (NF2) is an autosomal dominant syndrome characterized by the development of vestibular schwannomas and other tumors of the nervous system, including cranial and spinal meningiomas, schwannomas, and ependymomas. The presence of bilateral vestibular schwannomas is sufficient for the diagnosis. Skin manifestations are less common than in neurofibromatosis type 1 (NF1; von Recklinghausen disease). The apparent clinical distinction between NF1 and NF2 has been confirmed at the level of the gene locus by linkage studies; the gene for NF1 maps to chromosome 17, whereas the gene for NF2 has been assigned (in a single family) to chromosome 22. To increase the precision of the genetic mapping of NF2 and to determine whether additional susceptibility loci exist, we have performed linkage analysis on 12 families with NF2 by using four polymorphic markers from chromosome 22 and a marker at the NF1 locus on chromosome 17. Our results confirm the assignment of the gene for NF2 to chromosome 22 and do not support the hypothesis of genetic heterogeneity. We believe that chromosome 22 markers can now be used for presymptomatic diagnosis in selected families. The NF2 gene is tightly linked to the D22S32 locus (maximum lod score 4.12; recombination fraction 0). A CA-repeat polymorphism at the CRYB2 locus was the most informative marker in our families (lod score 5.99), but because the observed recombination fraction between NF2 and CRYB2 was 10 cM, predictions using this marker will need to be interpreted with caution.

Treatment of an aggressive non-Hodgkin's lymphoma during pregnancy with MACOP-B chemotherapy

Non-Hodgkin's lymphoma occurring during pregnancy is a rare event. A young woman at 18 weeks gestation with twins presented with a B-cell immunoblastic lymphoma. Combination chemotherapy with methotrexate, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin (MACOP-B) was instituted after limited staging. There was excellent response and the 12 weekly chemotherapy protocol was completed in 13 weeks. Twin male infants were born at 28 weeks gestation by cesarean section for premature labor. There was no evidence of any congenital malformations or hematologic suppressions. We believe this to be the first report of aggressive weekly chemotherapy during pregnancy; this approach to treatment in aggressive non-Hodgkin's lymphoma is both efficacious and safe.

Fetal heart rate changes associated with general anesthesia

Decreased fetal heart rate variability was noted 90 seconds after the induction of general anesthesia with sodium thiopentone and fentanyl in a patient undergoing basket extraction of a renal calculus at 30 weeks' gestation. The fetal sleep pattern lasted for 105 minutes after the anesthetic was discontinued, 45 minutes after the mother was fully awake.

Raising questions in clinical practice

Answers are required by family physicians to numerous questions during a day of patient care. This study examined the number of questions that arose during one day to which family physicians did not have an answer, the library resources to which the family physicians had access and used, and the relationship between the number of questions that arose in practice and library resources or use. Volunteer family physicians (N = 87) reported a mean of 6.8 questions. When accessing libraries, physicians relied primarily on their office and home libraries. Personal libraries had fewer than ten textbooks published since 1980 and subscriptions to fewer than five journals. T-test analysis indicated that the physician with the most questions practiced in the medical school community, was a graduate of a Canadian or United States medical school, and attended a course on problem raising and solving. The number of questions did not differ by the holdings in the physician's library, the age or sex profile of the patients, the number of patients seen or the frequency with which the physician used his personal library. Medical educators and librarians should provide educational opportunities to assist family physicians develop their personal libraries, their problem solving skills and their use of modern technology to access the literature.

Vasopressin concentration in cord blood: correlation with method of delivery and cord pH

Cord plasma vasopressin concentration, determined by radioimmunoassay, was higher in arterial than in venous blood in 122 (84%) infants; the highest vasopressin values were recorded in 21 acidotic infants (mean cord pH, 7.13) delivered per vaginam and the lowest values in 50 infants delivered by cesarean section. Cord vasopressin levels were not elevated in infants delivered by cesarean section because of obstructed labor. There was a lack of correlation between vasopressin levels and the length of labor or cervical dilatation; a significant correlation was found between cord arterial vasopressin values and pH. Low vasopressin values were recorded in a group of 22 healthy infants (mean cord pH, 7.29) delivered by low forceps operation.

The effects of medication during pregnancy

Each pregnant woman takes an average of four or five different drugs during her pregnancy and an undetermined number of other agents. What role drugs may play in the overall problem of fetal wastage is difficult to estimate; this concern raises the question of a proper risk/benefit ratio for both mother and fetus in administering any drug to the pregnant woman. Maternal indications for drug administration may outweigh the fetal risk.

The prenatal assessment of fetal health

This article reviews the objectives, indications and methods currently used to assess fetal health in pregnancies at risk of fetoplacental dysfunction. The graphic display of clinical data encourages the physician to recognize deviations from the norm and assists in the selection of patients for assessment by the more sophisticated tests of fetoplacental function.

Hormonal patterns in conceptual cycles and early pregnancy

Androstenedione, testosterone, progesterone and human chorionic gonadotrophin (HCG) in plasma and total oestrogens, luteinizing hormone (LH) and HCG in urine were measured in five women during conceptual cycles and in early pregnancy. There were increased levels in plasma and urine of all the hormones measured between 12 to 48 days after ovulation except progesterone. The concentration of this hormone in plasma decreased during this time. The possible sources of these hormones in early pregnancy are discussed.