"They were very very nice but just not very good": The interplay between resident-supervisor relationships and assessment in the emergency setting

Purpose

Clinical supervisors hesitate to report learner weaknesses, a widely documented phenomenon referred to as "failure to fail." They also struggle to discuss weaknesses with learners themselves. Their reluctance to report and discuss learner weaknesses threatens the validity of assessment-of-learning decisions and the effectiveness of assessment for learning. Personal and interpersonal factors have been found to act as barriers to reporting learners' difficulties, but the precise role of the resident-supervisor relationship remains underexplored, specifically in the emergency setting. This study aims to better understand if and how factors related to the resident-supervisor relationship are involved in assessment of and for learning in the emergency setting.

Methods

We conducted a qualitative study, using semistructured interviews of 15 clinical supervisors in emergency medicine departments affiliated with our institution. Transcripts were independently coded by three members of the team using an iterative mixed deductive-inductive thematic analysis approach. The team then synthesized the coding and discussed analysis following guidelines for thematic analysis.

Results

Participating emergency medicine supervisors valued resident-supervisor relationships built on collaboration and trust and believed that such relationships support learning. They described how these relationships influenced assessment of and for learning and how in turn assessment influenced the relationship. Almost all profiles of resident-supervisor relationships in our study could hinder the disclosing of resident weaknesses, through a variety of mechanisms. To protect residents and themselves from the discomfort of disclosing weaknesses and to avoid deteriorating the resident-supervisor relationship, many downplayed or even masked residents' difficulties. Supervisors who described themselves as able to provide negative assessment of and for learning often adopted a more distant or professional stance.

Conclusions

This study contributes to a growing literature on failure to fail by confirming the critical impact that the resident-supervisor relationship has on the willingness and ability of emergency medicine supervisors to play their part as assessors.

[Feedback Guide for direct observation of family medicine residents in Canada: a francophone tool]

BACKGROUND

There is no CanMEDS-FM-based milestone tool to guide feedback during direct observation (DO). We have developed a guide to support documentation of feedback for direct observation (DO) in Canadian family medicine (FM) programs.

METHODS

The Guide was designed in three phases with the collaboration of five Canadian FM programs with at least a French-speaking teaching site: 1) literature review and needs assessment; 2) development of the DO Feedback Guide; 3) testing the Guide in a video simulation context with qualitative content analysis.

RESULTS

Phase 1 demonstrated the need for a narrative guide aimed at 1) specifying mutual expectations according to the resident's level of training and the clinical context, 2) providing the supervisor with tools and structure in his observations 3) to facilitate documentation of feedback. Phase 2 made it possible to develop the Guide, in paper and electronic formats, meeting the needs identified. In phase 3, 15 supervisors used the guide for three levels of residence. The Guide was adjusted following this testing to recall the phases of the clinical encounter that were often forgotten during feedback (before consultation, diagnosis and follow-up), and to suggest types of formulation to be favored (stimulating questions, questions of clarification, reflections).

CONCLUSION

Based on evidence and a collaborative approach, this Guide will equip French-speaking Canadian supervisors and residents performing DO in family medicine.

Psychometric validation of the Laval developmental benchmarks scale for family medicine

BACKGROUND

With the implementation of competency-based education in family medicine, there is a need for summative end-of-rotation assessments that are criterion-referenced rather than normative. Laval University's family residency program therefore developed the Laval Developmental Benchmarks Scale for Family Medicine (DBS-FM), based on competency milestones. This psychometric validation study investigates its internal structure and its relation to another variable, two sources of validity evidence.

METHODS

We used assessment data from a cohort of residents (n = 1432 assessments) and the Rasch Rating Scale Model to investigate its reliability, dimensionality, rating scale functioning, targeting of items to residents' competency levels, biases (differential item functioning), items hierarchy (adequacy of milestones ordering), and score responsiveness. Convergent validity was estimated by its correlation with the clinical rotation decision (pass, in difficulty/fail).

RESULTS

The DBS-FM can be considered as a unidimensional scale with good reliability for non-extreme scores (.83). The correlation between expected and empirical items hierarchies was of .78, p < .0001.Year 2 residents achieved higher scores than year 1 residents. It was associated with the clinical rotation decision.

CONCLUSION

Advancing its validation, this study found that the DBS-FM has a sound internal structure and demonstrates convergent validity.

Analysis of Supervisors' Feedback to Residents on Communicator, Collaborator, and Professional Roles During Case Discussions

BACKGROUND

Literature examining the feedback supervisors give to residents during case discussions in the realms of communication, collaboration, and professional roles (intrinsic roles) focuses on analyses of written feedback and self-reporting.

OBJECTIVES

We quantified how much of the supervisors' verbal feedback time targeted residents' intrinsic roles and how well feedback time was aligned with the role targeted by each case. We analyzed the educational goals of this feedback. We assessed whether feedback content differed depending on whether the residents implied or explicitly expressed a need for particular feedback.

METHODS

This was a mixed-methods study conducted from 2017 to 2019. We created scripted cases for radiology and internal medicine residents to present to supervisors, then analyzed the feedback given both qualitatively and quantitatively. The cases were designed to highlight the CanMEDS intrinsic roles of communicator, collaborator, and professional.

RESULTS

Radiologists (n = 15) spent 22% of case discussions providing feedback on intrinsic roles (48% aligned): 28% when the case targeted the communicator role, 14% for collaborator, and 27% for professional. Internists (n = 15) spent 70% of discussions on intrinsic roles (56% aligned): 66% for communicator, 73% for collaborator, and 72% for professional. Radiologists' goals were to offer advice (66%), reflections (21%), and agreements (7%). Internists offered advice (41%), reflections (40%), and clarifying questions (10%). We saw no consistent effects when residents explicitly requested feedback on an intrinsic role.

CONCLUSIONS

Case discussions represent frequent opportunities for substantial feedback on intrinsic roles, largely aligned with the clinical case. Supervisors predominantly offered monologues of advice and agreements.

User-centered and theory-based design of a professional training program on shared decision-making with older adults living with neurocognitive disorders: a mixed-methods study

BACKGROUND

We know little about the best approaches to design training for healthcare professionals. We thus studied how user-centered and theory-based design contribute to the development of a distance learning program for professionals, to increase their shared decision-making (SDM) with older adults living with neurocognitive disorders and their caregivers.

METHODS

In this mixed-methods study, healthcare professionals who worked in family medicine clinics and homecare services evaluated a training program in a user-centered approach with several iterative phases of quantitative and qualitative evaluation, each followed by modifications. The program comprised an e-learning activity and five evidence summaries. A subsample assessed the e-learning activity during semi-structured think-aloud sessions. A second subsample assessed the evidence summaries they received by email. All participants completed a theory-based questionnaire to assess their intention to adopt SDM. Descriptive statistical analyses and qualitative thematic analyses were integrated at each round to prioritize training improvements with regard to the determinants most likely to influence participants' intention.

RESULTS

Of 106 participants, 98 completed their evaluations of either the e-learning activity or evidence summary (93%). The professions most represented were physicians (60%) and nurses (15%). Professionals valued the e-learning component to gain knowledge on the theory and practice of SDM, and the evidence summaries to apply the knowledge gained through the e-learning activity to diverse clinical contexts. The iterative design process allowed addressing most weaknesses reported. Participants' intentions to adopt SDM and to use the summaries were high at baseline and remained positive as the rounds progressed. Attitude and social influence significantly influenced participants' intention to use the evidence summaries (P < 0.0001). Despite strong intention and the tailoring of tools to users, certain factors external to the training program can still influence the effective use of these tools and the adoption of SDM in practice.

CONCLUSIONS

A theory-based and user-centered design approach for continuing professional development interventions on SDM with older adults living with neurocognitive disorders and their caregivers appeared useful to identify the most important determinants of learners' intentions to use SDM in their practice, and validate our initial interpretations of learners' assessments during the subsequent evaluation round.

CanMEDS Competencies in Family Medicine Residents: Can Criterion-Based Assessment Improve the Quality of Teacher Feedback?

This article was migrated. The article was marked as recommended. Background: The Université Laval family medicine program has developed an innovative computerized tool called the criterion-based Competency Assessment Tool (CAT), currently undergoing validity assessment. Methods: This study followed a qualitative design assessing written comments collected in the assessment reports from the cohorts before and after the implementation of the CAT (n pre = 200, n post = 200) in order to ascertain the tool's consequence validity. A deductive thematic content analysis was performed and pre- and post-implementation cohorts were compared. Findings: Overall feedback quality does not appear to have changed between cohorts. When analyzing CanMEDS roles separately, each is covered more often, but related comments appear to be less specific. The new report also seems to enable the teacher to tell more with the same number of words. Conclusions: Perhaps since the items are complete, exhaustive, and detailed enough to be self-explanatory, the tool helps the teacher to cover a wider area of competencies without the need to add many details with narrative comments. Consequence validity does not seem to have been substantially affected by changes in the family medicine resident's competency assessment, but the results do not support the contention that comment quality has improved either.

Professional training on shared decision making with older adults living with neurocognitive disorders: a mixed-methods implementation study

BACKGROUND

Shared decision making with older adults living with neurocognitive disorders is challenging for primary healthcare professionals. We studied the implementation of a professional training program featuring an e-learning activity on shared decision making and five Decision Boxes on the care of people with neurocognitive disorders, and measured the program's effects.

METHODS

In this mixed-methods study, we recruited healthcare professionals in family medicine clinics and homecare settings in the Quebec City area (Canada). The professionals signed up for training as a continuing professional development activity and answered an online survey before and after training to assess their knowledge, and intention to adopt shared decision making. We recorded healthcare professionals' access to each training component, and conducted telephone interviews with a purposeful sample of extreme cases: half had completed training and the other half had not. We performed bivariate analyses with the survey data and a thematic qualitative analysis of the interviews, as per the theory of planned behaviour.

RESULTS

Of the 47 participating healthcare professionals, 31 (66%) completed at least one training component. Several factors restricted participation, including lack of time, training fragmentation into several components, poor adaptation of training to specific professions, and technical/logistical barriers. Ease of access, ease of use, the usefulness of training content and the availability of training credits fostered participation. Training allowed Healthcare professionals to improve their knowledge about risk communication (p = 0.02), and their awareness of the options (P = 0.011). Professionals' intention to adopt shared decision making was high before training (mean ± SD = 5.88 ± 0.99, scale from 1 to 7, with 7 high) and remained high thereafter (5.94 ± 0.9).

CONCLUSIONS

The results of this study will allow modifying the training program to improve participation rates and, ultimately, uptake of meaningful shared decision making with patients living with neurocognitive disorders.

Le nouveau programme formel de mentorat du Collège québécois des médecins de famille

Problème à l’étude

Les stress inhérents à l’entrée en pratique peuvent décourager les futurs médecins de choisir la médecine de famille. Le Québec fait face à des problèmes de recrutement de médecins de famille en clinique pour remplacer ceux qui s’acheminent vers la retraite. Le mentorat s’avère être un moyen prometteur de soutenir la relève en médecine de famille.

Objectif du programme

Aider les médecins de famille en début de pratique à composer de manière satisfaisante avec les enjeux et les défis inhérents à l’insertion professionnelle et à leur développement personnel et professionnel.

Description du programme

D’une durée de 12 mois, il se caractérise par des dyades mentoré-mentor, à l’initiative des mentorés; des moyens de soutien aux mentors, dont une communauté de pratique; des modalités de rencontres favorisant la participation de mentorés et de mentors provenant de diverses régions géographiques du Québec.

Conclusion

L’engagement et le soutien des mentorés et des mentors sont des facteurs essentiels de réussite, mais aussi des défis organisationnels pour la pérennité de programmes formels de mentorat auprès des nouveaux médecins de famille du Québec.

Quebec College of Family Physicians' new formal mentorship program

PROBLEM ADDRESSED

The stresses that arise during the first years of practice can discourage future physicians from choosing family medicine. Quebec is experiencing challenges in recruiting clinical family physicians to replace those nearing retirement. Mentorship is a promising approach that supports future family physicians.

OBJECTIVE OF PROGRAM

To help family physicians at the beginning of their practice to adequately cope with the issues and challenges that come with professional integration and their personal and professional development.

PROGRAM DESCRIPTION

A 12-month program that pairs mentors with mentees, on the mentee's initiative; it provides supports for mentors (such as a community of practice), and it comprises meeting formats that encourage the participation of mentees and mentors from different geographic regions across Quebec.

CONCLUSION

Engaging and supporting mentees and mentors are essential to success, but might also present organizational challenges to sustaining formal mentorship programs for new family physicians in Quebec.

Talking about treatment benefits, harms, and what matters to patients in radiation oncology: an observational study

Background

Shared decision making is associated with improved patient outcomes in radiation oncology. Our study aimed to capture how shared decision-making practices–namely, communicating potential harms and benefits and discussing what matters to patients–occur in usual care.

Methods

We invited a convenience sample of clinicians and patients in a radiation oncology clinic to participate in a mixed methods study. Prior to consultations, clinicians and patients completed self-administered questionnaires. We audio-recorded consultations and conducted qualitative content analysis. Patients completed a questionnaire immediately post-consultation about their recall and perceptions.

Results

11 radiation oncologists, 4 residents, 14 nurses, and 40 patients (55% men; mean age 64, standard deviation or SD 9) participated. Patients had a variety of cancers; 30% had been referred for palliative radiotherapy. During consultations (mean length 45 min, SD 16), clinicians presented a median of 8 potential harms (interquartile range 6–11), using quantitative estimates 17% of the time. Patients recalled significantly fewer harms (median recall 2, interquartile range 0–3, t(38) = 9.3, p < .001). Better recall was associated with discussing potential harms with a nurse after seeing the physician (odds ratio 7.5, 95% confidence interval 1.3–67.0, p = .04.) Clinicians initiated 63% of discussions of harms and benefits while patients and families initiated 69% of discussions about values and preferences (Chi-squared(1) = 37.8, p < .001). 56% of patients reported their clinician asked what mattered to them.

Conclusions

Radiation oncology clinics may wish to use interprofessional care and initiate more discussions about what matters to patients to heed Jain’s (2014) reminder that, “a patient isn’t a disease with a body attached but a life into which a disease has intruded.”

How often do both core competencies of shared decision making occur in family medicine teaching clinics?

OBJECTIVE

To assess how often risk communication and values clarification occur in routine family medicine practice and to explore factors associated with their occurrence.

DESIGN

Qualitative and quantitative cross-sectional study.

SETTING

Five university-affiliated family medicine teaching clinics across Quebec.

PARTICIPANTS

Seventy-one health professionals (55% physicians, 35% residents, 10% nurses or dietitians) and 238 patients (76% women; age range 16 to 82 years old).

MAIN OUTCOME MEASURES

The presence or absence of risk communication and values clarification during visits in which decisions were made was determined. Factors associated with the primary outcome (both competencies together) were identified. The OPTION5 (observing patient involvement in decision making) instrument was used to validate the dichotomous outcome.

RESULTS

The presence of risk communication and values clarification during visits was associated with OPTION5 scores (area under the curve of 0.80, 95% CI 0.75 to 0.86, P < .001). Both core competencies of shared decision making occurred in 150 of 238 (63%) visits (95% CI 54% to 70%). Such an occurrence was more likely when the visit included discussion about beginning something new, treatment options, or postponing a decision, as well as when health professionals preferred a collaborative decision-making style and when the visit included more decisions or was longer. Alone, risk communication occurred in 203 of 238 (85%) visits (95% CI 82% to 96%) and values clarification in 162 of 238 (68%) visits (95% CI 61% to 75%).

CONCLUSION

Health professionals in family medicine are making an effort to engage patients in shared decision making in routine daily practice, especially when there is time to do so. The greatest potential for improvement might lie in values clarification; that is, discussing what matters to patients and families.

The Impact of a National Competency-Based Medical Education Initiative in Family Medicine

PURPOSE

Triple C is the Canadian competency-based medical education (CBME) initiative for family medicine. The authors report on a study exploring the impacts Triple C has had across Canada.

METHOD

A multi-institutional team conducted a realist study to explore the impact of Triple C implementation in different programs across Canada. Data were collected between March and June 2016 from interviews and focus groups with key medical school stakeholders. Data were analyzed using thematic and template analysis techniques.

RESULTS

Data were acquired from 16 of the 17 Canadian medical schools from a combination of program leaders, educators, and trainees. Triple C was implemented in different ways and to different extents depending on context. Newer sites tended to have a more comprehensive implementation than established sites. Urban sites afforded different opportunities to implement Triple C from those afforded by rural sites. Although it was too early to assess its impact on the quality of graduating residents, Triple C was seen as having had a positive impact on identifying and remediating failing learners and on energizing and legitimizing the educational mission in family medicine. Negative impacts included greater costs and tensions in the relationships with other specialties. A principles-based approach to CBME offered flexibility to programs to incorporate variation in their interpretation and implementation of Triple C. Although there was a degree of normalization of practice, it was not standardized across sites or programs.

CONCLUSIONS

Triple C has been successfully implemented across Canada but in differing ways and with different impacts.

Validation of the 5-item doctor-patient communication competency instrument for medical students (DPCC-MS) using two years of assessment data

BACKGROUND

Medical students on clinical rotations have to be assessed on several competencies at the end of each clinical rotation, pointing to the need for short, reliable, and valid assessment instruments of each competency. Doctor patient communication is a central competency targeted by medical schools however, there are no published short (i.e. less than 10 items), reliable and valid instruments to assess doctor-patient communication competency. The Faculty of Medicine of Laval University recently developed a 5-item Doctor-Patient Communication Competency instrument for Medical Students (DPCC-MS), based on the Patient Centered Clinical Method conceptual framework, which provides a global summative end-of-rotation assessment of doctor-patient communication. We conducted a psychometric validation of this instrument and present validity evidence based on the response process, internal structure and relation to other variables using two years of assessment data.

METHODS

We conducted the study in two phases. In phase 1, we drew on 4991 student DPCC-MS assessments (two years). We conducted descriptive statistics, a confirmatory factor analysis (CFA), and tested the correlation between the DPCC-MS and the Multiple Mini Interviews (MMI) scores. In phase 2, eleven clinical teachers assessed the performance of 35 medical students in an objective structured clinical examination station using the DPCC-MS, a 15-item instrument developed by Côté et al. (published in 2001), and a 2-item global assessment. We compared the DPCC-MS to the longer Côté et al. instrument based on internal consistency, coefficient of variation, convergent validity, and inter-rater reliability.

RESULTS

Phase 1: Cronbach's alpha was acceptable (.75 and .83). Inter-item correlations were positive and the discrimination index was above .30 for all items. CFA supported a unidimensional structure. DPCC-MS and MMI scores were correlated. Phase 2: The DPCC-MS and the Côté et al. instrument had similar internal consistency and convergent validity, but the DPCC-MS had better inter-rater reliability (mean ICC = .61).

CONCLUSIONS

The DPCC-MS provides an internally consistent and valid assessment of medical students' communication with patients.

Content and conceptual frameworks of psychology and social work preceptor feedback related to the educational requests of family medicine residents

OBJECTIVES

Supervision of communication competency in clinical settings in medicine is an important component of professional training. The purpose of this study was to describe the content and rationale of psychology and social work preceptor feedback to family medicine residents who express educational needs during case-based written vignettes.

METHODS

We conducted a qualitative study with 25 psychology and social work preceptors from family medicine departments of the three French-speaking universities in the province of Quebec, Canada. During an individual interview, preceptors were asked to respond to three short case-based written vignettes depicting resident educational issues regarding communication and to explain their responses. Authors analyzed the content of responses and the conceptual frameworks reported.

RESULTS

The three vignettes elicited 475 responses, including 58 distinct responses and 33 distinct conceptual frameworks. Therapeutic alliance and stages of grief were the two most reported conceptual frameworks.

CONCLUSION

The vignettes stimulated a wealth of responses and conceptual frameworks among psychology and social work preceptors in family medicine.

PRACTICAL IMPLICATIONS

The complete list of responses could be useful for faculty development activities by stimulating preceptors' reflexive practice with regard to their responses, the educational goals of these responses and the conceptual frameworks underlying their feedback.

Attitudes of pediatric intensive care unit physicians towards the use of cognitive aids: a qualitative study

Background

Cognitive aids are increasingly recommended in clinical practice, yet little is known about the attitudes of physicians towards these tools.

Methods

We employed a qualitative, descriptive design to explore physician attitudes towards cognitive aids in pediatric intensive care units (PICUs). Semi-structured interviews elicited the opinions of a convenience sample of practicing PICU physicians towards the use of cognitive aids. We analyzed interview data for thematic content to examine the three factors of intention to use cognitive aids as defined by the Theory of Planned Behavior (TPB), attitudes, social norms, and perceived control.

Results

Analysis of 14 interviews suggested that in the PICU setting, cognitive aids are widely used. Discovered themes related to their use touched on all three TPB factors of intention and included: aids are perceived to improve team communication; aids may improve patient safety; aids may hinder clinician judgment; physicians may resist implementation if it occurs prior to demonstration of benefit; effective adoption requires cognitive aids to be integrated into local workplace culture; and implementation should take physician concerns into account.

Conclusions

Our sample of PICU physicians were open to cognitive aids in their practice, as long as such aids preserve the primacy of clinical judgment, focus on team communication, demonstrate effectiveness through preliminary testing, and are designed and implemented with the local culture and work environment in mind. Future knowledge translation efforts to implement cognitive aids would benefit from consideration of these issues.

Influences of OSCE design on students' diagnostic reasoning

CONTEXT

Some characteristics of assessments exert a strong influence on how students study. Understanding these pre-assessment learning effects is of key importance to the designing of medical assessments that foster students' reasoning abilities. Perceptions of the task demands of an assessment significantly influence students' cognitive processes. However, why and how certain tasks positively 'drive' learning remain unknown. Medical tasks can be assessed as coherent meaningful whole tasks (e.g. examining a patient based on his complaint to find the diagnosis) or can be divided into simpler part tasks (e.g. demonstrating the physical examination of a pre-specified disease). Comparing the benefits of whole-task and part-task assessments in a randomised controlled experiment could guide the design of 'assessments for learning'.

OBJECTIVES

The purpose of this study was to determine whether the knowledge that an objective structured clinical examination (OSCE) will contain whole tasks, as opposed to part tasks, increases the use of diagnostic reasoning by medical students when they study for this assessment.

METHODS

In this randomised, controlled, mixed-methods experiment, 40 medical students were randomly paired and filmed while studying together for two imminent physical examination OSCE stations. Each 25-minute study period began with video cues and ended with a questionnaire on cognitive loads. Cues disclosed either a part-task OSCE station (examination of a healthy patient) or a whole-task OSCE station (hypothesis-driven physical examination [HDPE]). In a crossover design, sequences were randomised for both task and content (shoulder or spine). Two blinded and independent authors scored all 40 videos in distinct randomised orders, listening to participants studying freely. Mentioning a diagnosis in association with a sign was scored as a backward association, and the opposite was scored as a forward association; both revealed the use of diagnostic reasoning. Qualitative data were obtained through group interviews.

RESULTS

Studying for whole-task OSCE stations resulted in a greater use of diagnostic reasoning. Qualitative data triangulate these findings and show the precedence of cues sourced from the 'student grapevine'.

CONCLUSIONS

In comparison with 'traditional' part-task OSCEs, whole-task OSCEs like the HDPE increase students' use of diagnostic reasoning during study time.

Content and Rationale of Junior and Senior Preceptors Responding to Residents' Educational Needs Revisited

THEORY

Feedback and debriefing, as portrayed in expertise development and self-assessment, play critical roles in providing residents with useful information to foster their progress.

HYPOTHESES

Prior work has shown that clinical preceptors' use of conceptual frameworks (CFs; ways of thinking based on theories, best practices, or models) while giving feedback to residents was positively associated with a greater diversity of responses. Also, senior preceptors produced more responses, used more CFs, and asked more probing-challenging questions than junior preceptors. The purpose was to confirm the generalization of these initial findings with a broader and better defined sample of preceptors.

METHOD

We conducted a mixed-method study with 20 junior and 20 senior preceptors in a controlled environment to analyze their responses and rationales to residents' educational needs as portrayed in 6 written vignettes. The preceptors were recruited from 3 primary care specialties preceptors (family medicine, internal medicine, pediatrics) of the 3 French-speaking faculties of medicine in Québec, Canada.

RESULTS

The preceptors increased the 2012 list of response topics (96 to 126) and doubled the number of distinct CFs (16 to 32). The junior and senior preceptors expressed the same number and diversity of CFs. On average, senior preceptors asked more clarification questions and reflected more than juniors on the learning process that occurs during case discussions. Preceptor specialty and prior training in medical education did not influence the number and diversity of responses and CFs, except that preceptors with prior training generated more responses per vignette and were more reflective. Senior preceptors had a stronger positive relationship between the number of total and distinct CFs and the number of responses than the juniors.

CONCLUSIONS

Although senior preceptors did not give more responses or use more CFs compared to the prior study, they continue to probe residents more and reflected more. The positive relationship between responses and CFs has important implications for faculty development and calls for more research to better understand the specific contribution of CFs to feedback.

Collaboration between family physicians and nurse clinicians: opinions of graduates in family medicine

OBJECTIVE

To determine whether graduating family physicians are exposed to collaboration between family physicians and nurse clinicians during their training, as well as their opinions about shared care between doctors and nurse clinicians in the delivery of patient care.

DESIGN

Anonymous online survey.

SETTING

Two French-Canadian university family medicine residency programs.

PARTICIPANTS

The 2010 and 2011 graduating family physicians (N = 343) from the University of Montreal and Laval University in Quebec.

MAIN OUTCOME MEASURES

The extent to which nurse clinicians in graduating family physicians' training milieu were involved in preventive and curative patient care activities, and graduates' opinions about nurse clinicians sharing care with physicians.

RESULTS

Of 343 graduates, 186 (54.2%) participated in the survey. Although as residents in family medicine their exposure to shared care with nurse clinicians was somewhat limited, respondents indicated that they were generally quite open to the idea of sharing care with nurse clinicians. More than 70% of respondents agreed or strongly agreed that nurse clinicians could adjust, according to protocols of clinical guidelines, the treatment of patients with diabetes, hypertension, and asthma, as well as regulate medication for pain control in terminally ill patients. By contrast, respondents were less favourable to nurse clinicians adjusting the treatment of patients with depression. More than 80% of respondents agreed or strongly agreed that nurse clinicians could initiate treatment via a medical directive for routine hormonal contraception, acne, uncomplicated cystitis, and sexually transmitted infections. Respondents' opinions on nurse clinicians initiating treatment for pharyngitis and otitis were more divided.

CONCLUSION

Graduating family physicians are quite open to collaborating with nurse clinicians. Although they have observed some collaboration between physicians and nurses, there are areas of shared clinical activities in which they would benefit from further exposure and training.

Preceptors' understanding and use of role modeling to develop the CanMEDS competencies in residents

PURPOSE

Role modeling by preceptors is a key strategy for training residents in the competencies defined within the CanMEDS conceptual framework. However, little is known about the extent to which preceptors are aware of the importance of role modeling or how they perceive and enact it in their daily interactions with residents. The purpose of this study was to describe how preceptors understand and use role modeling to develop CanMEDS competencies in residents.

METHOD

In 2010, the authors conducted a descriptive qualitative study with preceptors in medical, surgical, and laboratory specialties who supervised residents on a regular basis at the Université Laval Faculty of Medicine (Québec, Canada). Respondents participated in semistructured, individual interviews. An inductive thematic analysis of interview transcripts was conducted using triangulation.

RESULTS

Most participants highlighted the importance of role modeling to support residents' development of the CanMEDS competencies, particularly communication, collaboration, and professionalism, which preceptors perceived as "less scientific" and the most difficult to teach. Although most participants reported using an implicit, unstructured role modeling process, some described more explicit strategies. Eight types of educational challenges in role modeling the CanMEDS competencies were identified, including encouraging reflective practice, understanding the competencies and their importance in one's specialty, and being aware of one's strengths and weaknesses as a clinical teacher.

CONCLUSIONS

Preceptors are aware of the importance of role modeling competencies for residents, but many do so only implicitly. This study's findings are important for improving strategies for role modeling and for the professional development of preceptors.

Collaboration between family physicians and community pharmacists: opinions of graduates in family medicine

OBJECTIVE

To ascertain the opinions of graduating family physicians about collaboration between family physicians and community pharmacists.

DESIGN

Anonymous online survey.

SETTING

Two French-Canadian university family medicine residency programs.

PARTICIPANTS

The 2010 and 2011 graduating family physicians (N = 343) from the University of Montreal and Laval University in Quebec.

MAIN OUTCOME MEASURES

Content of written prescriptions; frequency of and reasons for consultations with community pharmacists; and graduates' perceptions of sharing professional responsibilities with community pharmacists.

RESULTS

The response rate was 54.2%. Overall, graduates were open to collaborating actively with community pharmacists. For example, at least 60% of graduates reported that it was important to write on prescriptions about any changes to patients' medication and creatinine clearance. Most graduates responded positively to sharing responsibility for the adjustment of treatment of patients with certain chronic conditions (88.3% for anticoagulation, 64.7% for hypercholesterolemia, 61.2% for hypertension, and 60.6% for diabetes) and for the initiation of treatment of minor conditions according to a collective prescription (80.6% for traveler's diarrhea, 74.1% for juvenile acne, and 73.6% for allergic rhinitis). However, such interprofessional collaboration requires that each professional group continues to adapt to its roles and responsibilities.

CONCLUSION

Family medicine graduates are open to actively collaborating with community pharmacists, but they have some reservations regarding sharing certain responsibilities. As collaborative practices are changing, graduates' opinions should be documented once they are actually practising.

Use and teaching of pneumatic otoscopy in a family medicine residency program

OBJECTIVE

To determine to what extent FPs teach and use pneumatic otoscopy and to identify the chief influences on this behaviour.

DESIGN

Mixed-methods descriptive study conducted between March and May 2011.

SETTING

The family medicine residency program at Laval University in Quebec city, Que.

PARTICIPANTS

Directors of the family medicine teaching units (FMTUs), teachers, and residents.

METHODS

We used questionnaires to assess the availability of pneumatic otoscopy equipment in 12 FMTUs, current behaviour and behavioural intention among physicians (residents and teachers) to use or teach pneumatic otoscopy, and facilitators and barriers to these practices. We also conducted 2 focus groups to further explore the facilitators of and barriers to using pneumatic otoscopy. We used descriptive statistics for quantitative data, transcribed the qualitative material, and performed content analysis.

MAIN FINDINGS

Eight of the 12 FMTUs reported having pneumatic otoscopy equipment. Four had it in all of their consulting rooms, and 2 formally taught it. Nine (4%) of 211 physicians reported regular use of pneumatic otoscopy. Mean (SD) intention to teach or use pneumatic otoscopy during the next year was low (2.4 [1.0] out of 5). Teachers identified improved diagnostic accuracy as the main facilitator both for use and for teaching, while residents identified recommendation by practice guidelines as the main facilitator for use. All physicians reported lack of availability of equipment as the main barrier to use. The main barrier to teaching pneumatic otoscopy reported by teachers was that they did not use it themselves. In focus groups, themes of consequences, capabilities, and socioprofessional influences were most dominant. Residents clearly identified role modeling by teachers as facilitating the use of pneumatic otoscopy.

CONCLUSION

Pneumatic otoscopy is minimally used and taught in the family medicine residency program studied. Interventions to increase its use should target identified underlying beliefs and facilitators of and barriers to its use and teaching.

Using field notes to evaluate competencies in family medicine training: a study of predictors of intention

BACKGROUND

Documenting feedback during clinical supervision using field notes (FN) is a recommended competency-based evaluation strategy that will require changes in the culture of medical education. This study identified factors influencing the intention to adopt FN in family medicine training, using the theory of planned behaviour.

METHODS

This mixed-methods study involved clinical teachers (CT) and residents from two family medicine units. Main outcomes were: 1) intention (and its predictors: attitude, perceived behavioural control (PBC) and normative belief) to use FN, assessed using a 7-item Likert scale questionnaire (1: strongly disagree to 7: strongly agree) and 2) related salient beliefs, explored in focus groups three and six months after FN implementation.

RESULTS

27 CT and 28 residents participated. Intention to use FN was 6.20±1.20 and 5.74±1.03 in CT and residents respectively. Predictors of this intention were attitude and PBC (mutually influential: p < 0.05), and normative belief (p < 0.01). Focus groups identified underlying beliefs regarding their use (perceived advantages/disadvantages and facilitators/barriers).

CONCLUSION

Intention to adopt field notes to document competency is influenced by attitude, perceived behavioural control and normative belief. Implementation of field notes should be preceded by interventions that target the identified salient beliefs to improve this competency-based evaluation strategy.

How core competencies are taught during clinical supervision: participatory action research in family medicine

OBJECTIVES

The development of professional competence is the main goal of residency training. Clinical supervision is the most commonly used teaching and learning method for the development of core competencies (CCs). The literature provides little information on how to encourage the learning of CCs through supervision. We undertook an exploratory study to describe if and how CCs were addressed during supervision in a family medicine residency programme.

METHODS

We selected a participatory action research design to engage participants in exploring their precepting practices. Eleven volunteer faculty staff and six residents from a large family medicine residency programme took part in a 9-month process which included three focus group encounters alternating with data gathering during supervision. We used mostly qualitative methods for data collection and analysis, with thematic content analysis, triangulation of sources and of researchers, and member checking.

RESULTS

Participants realised that they addressed all CCs listed as programme outcomes during clinical supervision, albeit implicitly and intuitively, and often unconsciously and superficially. We identified a series of factors that influenced the discussion of CCs: (i) CCs must be both known and valued; (ii) discussion of CCs occurs in a constant adaptation to numerous contextual factors, such as residents' characteristics; (iii) the teaching and learning of CCs is influenced by six challenges in the preceptor-resident interaction, such as residents' active engagement, and (iv) coherence with other curricular elements contributes to learning about CCs. Differences between residents' and preceptors' perspectives are discussed.

CONCLUSIONS

This is the first descriptive study focusing on the teaching of CCs during clinical supervision, as experienced in a family medicine residency programme. Content and process issues were equally influential on the discussion of CCs. Our findings led to a representation of factors determining the teaching and learning of CCs in supervision, and suggest directions for research, for faculty development, and for interventions with learners.

Student uncertainties drive teaching during case presentations: more so with SNAPPS

PURPOSE

To compare the nature of uncertainties expressed by medical students using the six-step SNAPPS technique for case presentations (Summarize history and findings; N>arrow the differential; Analyze the differential; Probe preceptors about uncertainties; Plan management; Select case-related issues for self-study) versus those expressed by students doing customary presentations and to elucidate how preceptors respond.

METHOD

The authors performed a secondary analysis in 2009 of data from a 2004-2005 randomized study, comparing SNAPPS users' case presentations with other students' presentations. Authors coded transcriptions of audiotaped presentations to family medicine preceptors for type of student uncertainties, nature of preceptor responses, alignment of preceptor responses with uncertainty types, and expansion of preceptors' responses beyond addressing uncertainties.

RESULTS

The analysis included 19 SNAPPS and 41 comparison presentations. SNAPPS students expressed uncertainties in all case presentations, nearly twice as many as the comparison group (χ1df = 12.89, P = .0001). Most SNAPPS users' uncertainties (24/44 [55%]) focused on diagnostic reasoning compared with 9/38 (24%) for comparison students' (χ1df = 8.08, P = .004). Uncertainties about clinical findings and medications/management did not differ significantly between groups. Preceptors responded with teaching aligned with the uncertainties and expanded 24/66 (36%) of their comments.

CONCLUSION

Students can drive the content of the teaching they receive based on uncertainties they express to preceptors during case presentations. Preceptors are ready to teach at "the drop of a question" and align their teaching with the content of students' questions; these learning moments-in context and just-in-time-can be created by students.

Content and conceptual frameworks of preceptor feedback related to residents' educational needs

PURPOSE

The development of clinical expertise depends not only on frequent practice opportunities but also on receiving quality feedback, especially regarding difficult aspects of learning. The purpose of this study was to investigate the content and conceptual frameworks of preceptor feedback to residents during case presentations.

METHOD

The authors conducted a qualitative and correlational study in which 25 clinical preceptors from one Canadian medical school's internal medicine and family medicine residency programs responded to six written, case-based vignettes depicting residents seeking help regarding a variety of educational issues. Preceptors were asked probing follow-up questions about their responses. The authors analyzed response content, conceptual frameworks used in formulating responses, and the correlation between the two.

RESULTS

Overall, the preceptors generated 806 responses, representing 96 distinct topics. The five topics mentioned most frequently related to reading suggestions, leading diagnosis, contrasting clinical findings, patient follow-up, and resident's concerns/feelings about the case. Seventy-three percent of the topics were specific to one or two vignettes. The preceptors used 18 distinct conceptual frameworks in formulating responses (e.g., analytical versus nonanalytical reasoning, problem representation, therapeutic alliance, patient-centered approach). Use of conceptual frameworks was positively associated with greater diversity of responses (r = 0.43, P = .03).

CONCLUSIONS

The vignettes stimulated rich and extensive lists of topics and conceptual frameworks. These findings represent but one step in the exploration of the content and conceptual frameworks of preceptor feedback and of the interrelatedness of feedback content and process, which have important implications for teaching and faculty development.

Training family physicians in shared decision making for the use of antibiotics for acute respiratory infections: a pilot clustered randomized controlled trial

BACKGROUND

Experts estimate that the prevalence of antibiotics use exceeds the prevalence of bacterial acute respiratory infections (ARIs).

OBJECTIVE

To develop, adapt and validate DECISION+ and estimate its impact on the decision of family physicians (FPs) and their patients on whether to use antibiotics for ARIs.

DESIGN

Two-arm parallel clustered pilot randomized controlled trial.

SETTING AND PARTICIPANTS

Four family medicine groups were randomized to immediate DECISION+ participation (the experimental group) or delayed DECISION+ participation (the control group). Thirty-three FPs and 459 patients participated.

INTERVENTION

DECISION+ is a multiple-component, continuing professional development program in shared decision making that addresses the use of antibiotics for ARIs.

MAIN OUTCOME MEASURES

Throughout the pilot trial, DECISION+ was adapted in response to participant feedback. After the consultation, patients and FPs independently self-reported the decision (immediate use, delayed use, or no use of antibiotics) and its quality. Agreement between their decisional conflict was assessed. Two weeks later, patients assessed their decisional regret and health status.

RESULTS

Compared to the control group, the experimental group reduced its immediate use of antibiotics (49 vs. 33% absolute difference = 16%; P = 0.08). Decisional conflict agreement was stronger in the experimental group (absolute difference of Pearson's r = 0.26; P = 0.06). Decisional regret and perceptions of the quality of the decision and of health status in the two groups were similar.

DISCUSSION AND CONCLUSIONS

DECISION+ was developed successfully and appears to reduce the use of antibiotics for ARIs without affecting patients' outcomes. A larger trial is needed to confirm this observation.

Feasibility of a randomised trial of a continuing medical education program in shared decision-making on the use of antibiotics for acute respiratory infections in primary care: the DECISION+ pilot trial

Background

The misuse and limited effectiveness of antibiotics for acute respiratory infections (ARIs) are well documented, and current approaches targeting physicians or patients to improve appropriate use have had limited effect. Shared decision-making could be a promising strategy to improve appropriate antibiotic use for ARIs, but very little is known about its implementation processes and outcomes in clinical settings. In this matter, pilot studies have played a key role in health science research over the past years in providing information for the planning, justification, and/or refinement of larger studies. The objective of our study was to assess the feasibility and acceptability of the study design, procedures, and intervention of the DECISION+ program, a continuing medical education program in shared decision-making among family physicians and their patients on the optimal use of antibiotics for treating ARIs in primary care.

Methods

A pilot clustered randomised trial was conducted. Family medicine groups (FMGs) were randomly assigned, to either the DECISION+ program, which included three 3-hour workshops over a four- to six-month period, or a control group that had a delayed exposure to the program.

Results

Among 21 FMGs contacted, 5 (24%) agreed to participate in the pilot study. A total of 39 family physicians (18 in the two experimental and 21 in the three control FMGs) and their 544 patients consulting for an ARI were recruited. The proportion of recruited family physicians who participated in all three workshops was 46% (50% for the experimental group and 43% for the control group), and the overall mean level of satisfaction regarding the workshops was 94%.

Conclusions

This trial, while aiming to demonstrate the feasibility and acceptability of conducting a larger study, has identified important opportunities for improving the design of a definitive trial. This pilot trial is informative for researchers and clinicians interested in designing and/or conducting studies with FMGs regarding training of physicians in shared decision-making.

Trial Registration

Clinicaltrials.Gov NCT00354315

Does training family physicians in shared decision making promote optimal use of antibiotics for acute respiratory infections? Study protocol of a pilot clustered randomised controlled trial

BACKGROUND

In North America, although it varies according to the specific type of acute respiratory infections (ARI), use of antibiotics is estimated to be well above the expected prevalence of bacterial infections. The objective of this pilot clustered randomized controlled trial (RCT) is to assess the feasibility of a larger clustered RCT aiming at evaluating the impact of DECISION+, a continuing professional development (CPD) program in shared decision making, on the optimal use of antibiotics in the context of ARI.

METHODS/DESIGN

This pilot study is a cluster RCT conducted with family physicians from Family Medicine Groups (FMG) in the Quebec City area, Canada. Participating FMG are randomised to an immediate DECISION+ group, a CPD program in shared decision making, (experimental group), or a delayed DECISION+ group (control group). Data collection involves recruiting five patients consulting for ARI per physician from both study groups before (Phase 1) and after (Phase 2) exposure of the experimental group to the DECISION+ program, and after exposure of the control group to the DECISION+ program (Phase 3). The primary outcome measures to assess the feasibility of a larger RCT include: 1) proportion of contacted FMG that agree to participate; 2) proportion of recruited physicians who participate in the DECISION+ program; 3) level of satisfaction of physicians regarding DECISION+; and 4) proportion of missing data in each data collection phase. Levels of agreement of the patient-physician dyad on the Decisional Conflict Scale and physicians' prescription profile for ARI are performed as secondary outcome measures.

DISCUSSION

This study protocol is informative for researchers and clinicians interested in designing and/or conducting clustered RCT with FMG regarding training of physicians in shared decision making.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00354315.

Introduction to core competencies in residency: a description of an intensive, integrated, multispecialty teaching program

Postgraduate residency programs must ensure that residents are properly trained in all core competencies. The CanMEDS framework of the Royal College of Physicians and Surgeons of Canada has established seven such competencies: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. The authors describe an integrated, one-month multispecialty rotation for first-year residents, Introduction to CanMEDS Core Competencies, at Laval University, Quebec, Canada. The goal of the rotation was to offer an in-depth and simultaneous training in each of the seven competencies. A pilot rotation was offered from February 9 to March 7, 2004 and involved 42 residents from seven programs and 30 faculty. It addressed 12 content areas related to the core competencies, through teaching formats promoting experiential and reflective learning. It involved three significant innovations: an intensive month-long format, during which residents were freed from most clinical duties; a multispecialty teaching and socialization strategy between peers and with faculty; and an integrated reflective approach, to ensure residents' understanding of the relevance and application of the core competencies in their own specialty. Although demanding to organize, the pilot rotation was well received. Residents were rapidly introduced to all competencies, and they developed an integrated perspective of them. An evaluation of impact is underway.

Primary health care professionals' views on barriers and facilitators to the implementation of the Ottawa Decision Support Framework in practice

OBJECTIVE

To describe primary health care professionals' views on barriers and facilitators for implementing the Ottawa Decision Support Framework (ODSF) in their practice.

METHODS

Thirteen focus groups with 118 primary health care professionals were performed. A taxonomy of barriers and facilitators to implementing clinical practice guidelines was used to content-analyse the following sources: reports from each workshop, field notes from the principal investigator and written materials collected from the participants.

RESULTS

Applicability of the ODSF to the practice population, process outcome expectation, asking patients about their preferred role in decision making, perception that the ODSF was modifiable, time issues, familiarity with the ODSF and its practicability were the most frequently identified both as barriers as well as facilitators. Forgetting about the ODSF, interpretation of evidence, challenge to autonomy and total lack of agreement with using the ODSF in general were identified only as barriers. Asking about values, health professional's outcome expectation, compatibility with the patient-centered approach or the evidence-based approach, ease of understanding and implementation, and ease of communicating the ODSF were identified only as facilitators.

CONCLUSION

These results provide insight on the type of interventions that could be developed in order to implement the ODSF in academic primary care practice.

PRACTICE IMPLICATIONS

Interventions to implement the ODSF in primary care practice will need to address a broad range of factors at the levels of the health professionals, the patients and the health care system.

Supporting patients facing difficult health care decisions: use of the Ottawa Decision Support Framework

OBJECTIVE

To investigate family physicians' views on factors that make health care decisions difficult for patients, interventions family physicians use to support patients making decisions, and interventions proposed by the Ottawa Decision Support Framework (ODSF).

DESIGN

Thirteen group discussions.

SETTING

Five family practice units.

PARTICIPANTS

One hundred twenty family physicians.

INTERVENTIONS

The multifaceted implementation intervention consisted of feedback from participants, a reminder at point of care, and an interactive workshop. During the workshop, family physicians were asked about their views on 2 videos both showing the concluding phase of a simulated clinical encounter with a woman facing a decision about hormone therapy. One video showed usual care; the other showed use of the ODSF process and related tools. Content was analyzed using observations by non-participants, field notes, material collected from participants during workshops, evaluation forms completed at the end of workshops, and comments written on exit questionnaires from the implementation trial.

MAIN OUTCOME MEASURES

Family physicians' views on the types of difficult decisions their patients face, the factors that make decisions difficult for patients, the interventions family physicians use to support patients' decisions, and the interventions proposed by the ODSF.

RESULTS

The 2 most frequently cited factors making decisions difficult for patients were experiencing uncertainty and fears about adverse outcomes. Before being introduced to the ODSF, participants had used mostly information-related strategies to provide decision support. After learning about the ODSF, participants overwhelmingly identified assessing patients' values as a priority. At the end of the workshop, the 5 changes in practice participants most frequently intended to make were, in order of importance, to assess patients' values, to ask about patients' preferred role in decision making, to screen for decisional conflict, to assess support or undue pressure on patients, and to increase patients' involvement in decision making.

CONCLUSION

The ODSF process and related tools have the potential to broaden family physicians' views on supporting patients facing difficult decisions.

Appraising qualitative research articles in medicine and medical education

Although qualitative research is gaining recognition in medicine and in medical education, most clinical teachers do not know how to perform a critical appraisal of articles in these fields. This article describes a grid for the critical appraisal of qualitative research articles so that clinical teachers are in a better position to evaluate this type of research and to teach the critical appraisal of it. The grid is comprised of 12 items with an explanation and suggestions for additional reading for each item.

[The patient-centered interview and the way it is taught. What do family physicians who have recently received their degree think?]

OBJECTIVE

To describe how family physicians perceive the patient-centred interview (PCI) and the way in which it is taught during residency training.

DESIGN

Mailed survey.

SETTING

Family physicians from a variety of practice settings in Quebec.

PARTICIPANTS

Ninety-one family physicians who graduated from Laval University between 1996 and 1998.

METHOD

Survey was conducted in 1999 using the modified Dillman method. The original questionnaire had mainly open-ended questions on perception of the PCI and learning activities associated with it during residency training. All qualitative data were subject to content analysis using triangulation strategies.

MAIN FINDINGS

A PCI mainly involves exploring patients' experience of their illnesses; this helps physicians to better understand patients. Patients are more content with this type of interview and are, therefore, more likely to follow physicians' recommendations. Respondents reported the main drawback to be longer interview times; this was particularly true for emergency and walk-in care. The most useful learning activities during residency were reported to be supervision by direct observation and observation of supervisor-patient consultations.

CONCLUSION

Patient-centred interviews enabled physicians to understand and help their patients better. Results of this study can help teachers who are developing and consolidating activities to teach residents how to conduct PCIs and how to integrate them into practice.

Senior residents' views on the meaning of professionalism and how they learn about it

PURPOSE

To determine senior residents' views on the meaning of professionalism and how they learned about it.

METHOD

By means of a modified Dillman technique, all senior residents at two faculties of medicine (n = 533) were surveyed about professionalism during the 1998-99 academic year. The residents were asked to list attributes of professionalism and to rank methods they found most useful for learning about professionalism, to rate the adequacy and quality of their teaching about professionalism and their comfort in explaining the concept of professionalism to a more junior trainee, to list suggestions about how teaching about professionalism could be improved, and to name the medical organization most concerned with matters of professionalism.

RESULTS

A total of 258 residents (48.4%) responded. They listed 1,052 attributes they associated with professionalism. The three most common attributes, all listed by more than 100 respondents, were respect, competence, and empathy. The respondents had learned the most about professionalism from observing role models, they rated the quantity and quality of teaching about it positively, and they felt comfortable explaining professionalism to a junior resident. Only 56% of the residents correctly identified the Canadian medical organization most concerned with professionalism.

CONCLUSION

Residents' knowledge about professionalism reflects their early stage of development as physicians and their daily activities, where such aspects of professionalism as the social contract, codes of ethics, participation in professional societies, and altruism are not highlighted. Residency programs should develop teaching activities focusing on professionalism that relate to issues residents face in their daily work.

[Evaluation of the physician-patient relationship competence. Development and validation of an assessment instrument]

OBJECTIVE

To develop and validate the design of a grid that assesses doctor-patient relationship skills.

DESIGN

Evaluation study of an assessment instrument.

SETTING

Private practices and family practice units.

PARTICIPANTS

From a sample of volunteers, 100 family physicians either in private practice or in a family practice unit completed the proposed grid independently.

MAIN OUTCOME MEASURES

The Cronbach alpha coefficient was used to analyze internal consistency. Factorial analysis was used to determine whether the grid's anticipated dimensions were in fact present.

RESULTS

The Cronbach alpha coefficient had a very high value (0.92), indicating that the items in the grid were highly homogeneous. Two key factors emerged from the factorial analysis; the first factor alone (understanding patients' experience) accounted for almost 42% of the variance.

CONCLUSION

The proposed grid presents some interesting metrologic qualities. It is short and relatively simple to use to assess relationship skills of future and practising family physicians. The grid must now be further validated using a variety of cases.

Mutations in activation-induced cytidine deaminase in patients with hyper IgM syndrome

Recent studies have shown that mutations in a newly described RNA editing enzyme, activation-induced cytidine deaminase (AID), can cause an autosomal recessive form of hyper IgM syndrome. To determine the relative frequency of mutations in AID, we evaluated a group of 27 patients with hyper IgM syndrome who did not have defects in CD40 ligand and 23 patients with common variable immunodeficiency. Three different mutations in AID were identified in 18 patients with hyper IgM syndrome, including 14 French Canadians, 2 Lumbee Indians, and a brother and sister from Okinawa. No mutations were found in the remaining 32 patients. In the group of patients with hyper IgM syndrome, the patients with mutations in AID were older at the age of diagnosis, were more likely to have positive isohemagglutinins, and were less likely to have anemia, neutropenia, or thrombocytopenia. Lymphoid hyperplasia was seen in patients with hyper IgM syndrome and normal AID as well as the patients with hyper IgM syndrome and defects in AID.

How clinical teachers perceive the doctor-patient relationship and themselves as role models

PURPOSE

Teachers must be good role models. In order to act the part, however, they must reflect on and articulate the attitudes and behaviors they wish to convey. The aim of this study was to describe how clinicians who teach clerks and residents represent the doctor-patient relationship and how they see themselves as role models for this relationship.

METHOD

In the fall of 1997, 28 clinical teachers in family medicine and various medical and surgical specialties at Laval University Faculty of Medicine participated in individual semistructured interviews regarding their perceptions of the doctor-patient relationship and how it is taught. The interviews were conducted by a trained research assistant and the content of the interviews was coded by three independent observers, who then performed a qualitative analysis.

RESULTS

The clinical teachers identified competencies associated with the doctor-patient relationship that differed in complexity and specificity. Paramount among these competencies were the ability to conduct interviews effectively and politely, the ability to understand and involve the patient, and, in some cases, the ability to handle emotionally-charged situations. The clinical teachers tended to demand more of their students in doctor-patient relationships than they did of themselves. Lack of time and a negative attitude toward the doctor-patient relationship, on the part of both teachers and students, were obstacles to teaching and learning this essential competency, even to the point of making it difficult for teachers to demonstrate and supervise these competencies during their daily clinical activities.

CONCLUSIONS

Most of the teachers had difficulty describing situations or behaviors in which they modeled the doctor-patient relationship. Being a role model requires a fairly precise idea of what one is modeling and accomplishing, and what one wants trainees to understand about the relationship. Efforts must be made to help clinical teachers to integrate the doctor-patient relationship into their clinical supervision and to provide them with tools to demonstrate this relationship effectively.

Multicenter comparison of Roche COBAS AMPLICOR MONITOR version 1.5, Organon Teknika NucliSens QT with Extractor, and Bayer Quantiplex version 3.0 for quantification of human immunodeficiency virus type 1 RNA in plasma

The performance and characteristics of Roche COBAS AMPLICOR HIV-1 MONITOR version 1.5 (CA MONITOR 1.5) UltraSensitive (usCA MONITOR 1. 5) and Standard (stCA MONITOR 1.5) procedures, Organon Teknika NucliSens HIV-1 RNA QT with Extractor (NucliSens), and Bayer Quantiplex HIV RNA version 3.0 (bDNA 3.0) were compared in a multicenter trial. Samples used in this study included 460 plasma specimens from human immunodeficiency virus (HIV) type 1 (HIV-1)-infected persons, 100 plasma specimens from HIV antibody (anti-HIV)-negative persons, and culture supernatants of HIV-1 subtype A to E isolates diluted in anti-HIV-negative plasma. Overall, bDNA 3.0 showed the least variation in RNA measures upon repeat testing. For the Roche assays, usCA MONITOR 1.5 displayed less variation in RNA measures than stCA MONITOR 1.5. NucliSens, at an input volume of 2 ml, showed the best sensitivity. Deming regression analysis indicated that the results of all three assays were significantly correlated (P < 0.0001). However, the mean difference in values between CA MONITOR 1.5 and bDNA 3.0 (0.274 log(10) RNA copies/ml; 95% confidence interval, 0.192 to 0.356) was significantly different from 0, indicating that CA MONITOR 1.5 values were regularly higher than bDNA 3.0 values. Upon testing of 100 anti-HIV-negative plasma specimens, usCA MONITOR 1.5 and NucliSens displayed 100% specificity, while bDNA 3.0 showed 98% specificity. NucliSens quantified 2 of 10 non-subtype B viral isolates at 1 log(10) lower than both CA MONITOR 1.5 and bDNA 3.0. For NucliSens, testing of specimens with greater than 1,000 RNA copies/ml at input volumes of 0.1, 0.2, and 2.0 ml did not affect the quality of results. Additional factors differing between assays included specimen throughput and volume requirements, limit of detection, ease of execution, instrument work space, and costs of disposal. These characteristics, along with assay performance, should be considered when one is selecting a viral load assay.

Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools

BACKGROUND AND OBJECTIVES

The training of caring physicians represents an important goal of medical education. Little is known however, on whether medical faculty constitute good role models for teaching humanistic skills to medical students. In this study, we examined to what extent medical students at innovative and traditional schools perceived their teachers as humanistic physicians and teachers. We also explored whether pre-clinical and clinical students shared the same perceptions.

METHODS

A mail survey was conducted in Canada of all second-year students and senior clerks at one innovative medical school (problem-based learning (PBL), patient-centred, community-oriented) and three traditional medical schools. Students were asked to what extent they agreed or disagreed that the majority of their teachers behaved as humanistic physicians and teachers; 10 statements were used. Overall, 65% of the 1039 students returned the questionnaire.

RESULTS

Over 25% of second-year students and 40% of senior clerks did not agree that their teachers behaved as humanistic caregivers with patients or were good role models in teaching the doctor-patient relationship. More than half of second-year students and senior clerks did not agree that their teachers valued human contact with them or were supportive of students who had difficulties. There were few differences in the way medical students at innovative and traditional schools perceived their teachers' humanistic qualities. At the pre-clinical level however, there were more students from the innovative school than from the traditional schools (around 60% vs. 40%, P < 0.005) who agreed that their teachers valued human contact with them and were supportive of students.

CONCLUSION

Our results indicate that the PBL curriculum fosters better teacher-student relationships during the pre-clinical years. They also suggest that an unacceptably large number of medical students are taught by physicians who seem to lack compassion and caring in their interactions with patients. This study questions the adequacy of medical faculty as role models for the acquisition of caring competence by medical students.

A physician-centred intervention to shorten hospital stay: a pilot study

BACKGROUND

Studies of length of stay (LOS) in hospital usually focus on physician-independent factors. In this study, the authors identified physician-dependent factors and tested an intervention aimed at them to determine its effect on LOS.

METHODS

A prospective comparison of LOS on 2 general medical wards in a tertiary care teaching hospital before and after the intervention. The pre-intervention (control) period and the intervention period were each 4 weeks. The intervention consisted of a checklist for planning management and discharge.

RESULTS

Overall, the mean LOS was shorter during the intervention period than during the control period, but the difference was not statistically significant (12.0 and 14.4 days respectively, p = 0.13). The difference was significant on ward A (11.0 v. 14.7 days respectively, p = 0.02) but not on ward B (13.0 and 14.0 days respectively, p = 0.90).

INTERPRETATION

An intervention at the level of the admitting physician may help to shorten LOS on a general medical ward.

[Physician-patient relations in family medicine]

PROBLEM ADDRESSED

In addition to clinical instruction, residents need "people" skills that will enable them to deal with all sorts of patients in difficult clinical situations. We planned a series of 12 seminars to teach these skills to first-year residents. OBJECTIVES OF PROGRAM: To ask relevant questions typical of the patient-centred approach; with empathy and respect, to encourage patients to express their emotions; to become more aware of one's own emotions and reactions in one's work as a physician; to negotiate with patients, taking into account both the patient's agenda and one's own.

MAIN COMPONENTS OF PROGRAM

Clinical problems drawn from a list of situations likely to involve difficult contact with patients were used to achieve program objectives. Various teaching methods (discussion, brief presentation, practical demonstration, role play) were used during the four stages of skills development: information, demonstration, practice, and feedback. Various tools were used to test the program.

CONCLUSION

Proper planning requires ongoing exploration of objectives, content, teaching methods, and evaluation. This discussion of the teaching principles applied in planning our seminars might inspire others to develop similar programs.