Engineering topological states in atom-based semiconductor quantum dots

The realization of controllable fermionic quantum systems via quantum simulation is instrumental for exploring many of the most intriguing effects in condensed-matter physics^1–3. Semiconductor quantum dots are particularly promising for quantum simulation as they can be engineered to achieve strong quantum correlations. However, although simulation of the Fermi–Hubbard model⁴ and Nagaoka ferromagnetism⁵ have been reported before, the simplest one-dimensional model of strongly correlated topological matter, the many-body Su–Schrieffer–Heeger (SSH) model^6–11, has so far remained elusive—mostly owing to the challenge of precisely engineering long-range interactions between electrons to reproduce the chosen Hamiltonian. Here we show that for precision-placed atoms in silicon with strong Coulomb confinement, we can engineer a minimum of six all-epitaxial in-plane gates to tune the energy levels across a linear array of ten quantum dots to realize both the trivial and the topological phases of the many-body SSH model. The strong on-site energies (about 25 millielectronvolts) and the ability to engineer gates with subnanometre precision in a unique staggered design allow us to tune the ratio between intercell and intracell electron transport to observe clear signatures of a topological phase with two conductance peaks at quarter-filling, compared with the ten conductance peaks of the trivial phase. The demonstration of the SSH model in a fermionic system isomorphic to qubits showcases our highly controllable quantum system and its usefulness for future simulations of strongly interacting electrons.

Precision-engineered devices consisting of a linear array of ten quantum dots are used to realize both the trivial and topological phases of the many-body Su–Schrieffer–Heeger model.

Alcohol, drug misuse and suicide attempts: unrecognised causes of out of hospital cardiac arrests admitted to intensive care units

AIM

To assess the contribution of alcohol, drug abuse and suicide attempts to out of hospital cardiac arrests (OHCA) who are admitted to our intensive care unit (ICU).

METHODS

Retrospective review of all OHCA admitted to the ICU over a 2-year period.

RESULTS

There were 26 OHCA. Six patients survived, all of whom had a cardiac aetiology for their arrest. Ten patients arrested due to external factors (drug misuse n = 4, alcohol excess n = 1, suicide attempts n = 4 and accidental choking n = 1). All of the patients who arrested secondary to external factors were young (37.2 +/- 13.58 years), 90% were male and all died in hospital. All of the cases of drug misuse involved cocaine.

CONCLUSION

Alcohol, drug misuse and suicide attempts contribute significantly to the number of OHCA which are admitted to ICU. Moreover, cocaine usage has contributed to a number of OHCA in our study.

Determinants of competency judgments by experienced laparoscopic surgeons

BACKGROUND

The definitive criteria for assessing competence remain elusive. In our study, we aimed to identify the determinants of competence assessment used by individual laparoscopic surgeons.

METHODS

In a blinded fashion, five laparoscopic surgeons rated 27 subjects on three laparoscopic simulations in four skill categories: clinical judgment, dexterity, serial/simultaneous complexity, and spatial orientation. The raters then assessed overall subject competence for each procedure. Point-biserial correlational analyses and cluster analyses were performed to ascertain the relationships among the various scales.

RESULTS

All of the correlations between the skills' ratings and competence judgments were statistically significant ( p <.05). No skill rating was consistently more highly correlated with the competence rating. There were no distinct patterns of correlations for each rater or each procedure. One factor emerged from each cluster analysis of the skills measures.

CONCLUSIONS

The results suggest that the four skills scored in the study are highly correlated with each other and are important in determining competence. The cluster analyses revealed that the surgeon raters shared a common perception of competence.

Evaluating minimally invasive surgery training using low-cost mechanical simulations

BACKGROUND

The goal of this study was to develop, test, and validate the efficacy of inexpensive mechanical minimally invasive surgery (MIS) model simulations for training faculty, residents, and medical students. We sought to demonstrate that trained and experienced MIS surgeon raters could reliably rate the MIS skills acquired during these simulations.

METHODS

We developed three renewable models that represent difficult or challenging segments of laparoscopic procedures; laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), and laparoscopic inguinal hernia (LH). We videotaped 10 students, 12 surgical residents, and 1 surgeon receiving training on each of the models and again during their posttraining evaluation session. Five MIS surgeons then assessed the evaluation session performance. For each simulation, we asked them to rate overall competence (COM) and four skills: clinical judgment (respect for tissue) (CJ), dexterity (economy of movement) (DEX), serial/simultaneous complexity (SSC), and spatial orientation (SO). We computed intraclass correlation (ICC) coefficients to determine the extent of agreement (i.e., reliability) among ratings.

RESULTS

We obtained ICC values of 0.74, 0.84, and 0.81 for COM ratings on LH, LC, and LA, respectively. We also obtained the following ICC values for the same three models: CJ, 0.75, 0.83, and 0.89; DEX, 0.88, 0.86, and 0.89; SSC, 0.82, 0.82, and 0.82; and SO, 0.86, 0.86, and 0.87, respectively.

CONCLUSIONS

We obtained very high reliability of performance ratings for competence and surgical skills using a mechanical simulator. Typically, faculty evaluations of residents in the operating room are much less reliable. In contrast, when faculty members observe residents in a controlled, standardized environment, their ratings can be very reliable.

Ventilator-patient dyssynchrony induced by change in ventilation mode

Patient-ventilator interactions may be coordinated (synchronous) or uncoordinated (dyssynchronous). Ventilator-patient dyssynchrony increases the work of breathing by imposing a respiratory muscle workload. Respiratory centre output responds to feedback from respiratory muscle loading. Mismatching of respiratory centre output and mechanical assistance results in dyssynchrony. We describe a case of severe patient-ventilator dyssynchrony and hypothesize that dyssynchrony was induced by a change in mode of ventilation from pressure-cycled to volume-cycled ventilation, due to both ventilator settings and by the patient's own respiratory centre adaptation to mechanical ventilation. The causes, management and clinical implications of dyssynchrony are discussed.

Need for comprehensive women's health continuing medical education among primary care physicians

BACKGROUND

The Council on Graduate Medical Education's (COGME) Fifth Report on Women and Medicine states that "changes in undergraduate and graduate medical education, in addition to continuing medical education, are needed to address adequately the comprehensive health needs of women." Primary care physicians (PCPs) who completed residency training prior to the establishment of new guidelines for women's health education are dependent on continuing medical education (CME) to update their knowledge and skills.

METHODS

Primary care physicians attending a university-based CME program in family medicine were surveyed (n = 300) about their need for CME in women's health topics. Responses were analyzed using chi-square analysis and Pearson correlations. Topics of interest were compared with women's health competencies published in 1997 by the American Board of Internal Medicine (ABIM) and in 1997 by the American Academy of Family Physicians (AAFP).

RESULTS

Of 30 women's health topics listed, 22 were of interest to 50% or more of respondents and 11 were of very high interest (p < .05). Respondents most interested in women's health CME were most likely to believe CME would reduce the number of referrals currently required to evaluate women's breast problems. Topics of interest also align well with ABIM and AAFP competencies in women's health. CME in comprehensive women's health care is therefore of high interest to our respondents and topics of greatest interest are identified.

IMPLICATIONS

Areas of interest correlate well with new requirements by ABIM and AAFP and should be targeted by CME programs.

A multidimensional approach to breast cancer education

BACKGROUND

This study was undertaken to present a multidimensional breast cancer education package (BCEP) to medical students in an effort to improve breast cancer education.

METHODS

The students were exposed to a four-part BCEP consisting of a hands-on structured clinical instruction module (SCIM), a lecture, a problem-based learning (PBL) small-group discussion, and a written manual. Each component was evaluated with a questionnaire. Students responded to the items using a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).

RESULTS

The mean overall evaluations for the BCEP components were: SCIM, 4.6; lecture, 4.0; manual 3.8, and PBL discussion, 3.6. Highly rated qualities of the SCIM included organization (4.7), faculty preparedness (4.8), and opportunity to practice skills (4.5). The students agreed that the lecture (4.1), manual (3.8), and PBL discussion (4.2) had prepared them for the SCIM.

CONCLUSION

This innovative BCEP effectively improved students' understanding of breast cancer.

The relative contributions of interpersonal and specific clinical skills to the perception of global clinical competence

BACKGROUND

The objective structured clinical examination (OSCE), an established instrument for evaluating resident competence, was used to test the hypothesis that faculty assessment of clinical competence in residents at various levels of training may be influenced more by general skills as a physician and less by competency in the actual skills being specifically tested. In this study, advantage was taken of the anticipated observation that general surgery residents did not demonstrate improvement in their ability to perform a focused neurological assessment over time.

METHODS

An OSCE, which was administered to 56 general surgery residents at all levels of training, included the assessment of a specific clinical neurosurgical problem (sciatica). Univariate and multivariate analyses were used to evaluate the relationship between the global faculty judgment of competent or noncompetent and the other performance measures that were applied.

RESULTS

At different levels of training, there was no observed difference in the specific skills being tested; nevertheless, junior and senior residents were more likely than incoming interns to be judged "competent" and received better evaluations of how well they introduced themselves to the patient. The competence judgment correlated significantly with all of the other performance measures, including the skills being tested.

CONCLUSIONS

The perception of competence is not solely dependent upon the particular skills under scrutiny. General competence does not guarantee competence in each specific skill set of a medical specialty.

Interpreting the judgment of surgical faculty regarding resident competence

BACKGROUND

It is reasonable to propose that competence is a multifaceted characteristic defined in part by some minimum level of knowledge and skill. In this study we examined the relationship between surgical faculty's judgment of clinical competence, as measured by a surgical resident objective structured clinical examination (OSCE), and the residents' objective performance on the skills being tested.

METHODS

Fifty-six general surgery residents at all levels of training participated in a 30-station OSCE. At the completion of each station, the faculty proctor made several overall judgments regarding each resident's performance, including a global judgment of competent or not competent. The competence judgment was applied to the objective percentage performance score in three different ways to construct methods for determining competence based solely upon this objective percentage score.

RESULTS

The average mean competent score (MCS) across the stations was 61%, and the average mean noncompetent score (MNCS) was 38%. The difference between MCS and MNCS for each station was very consistent. Upper threshold scores above which a judgment of competent was always made, and lower threshold scores below which a judgment of noncompetent was always made were observed. Overall, the average mean and threshold scores for competent and noncompetent groups were remarkably similar. For performance scores in the range between the threshold competent and noncompetent scores at each station, measures other than objective performance on the skills being evaluated determined the judgment of competent or not competent.

CONCLUSIONS

Empirically determined minimum acceptable standards for objective performance in clinical skills and knowledge appeared to have been subconsciously applied to the competence judgment by the faculty evaluators in this study. Other factors appeared to have become determinate when the objective performance score fell within a range of uncertainty.

Assessing residents' clinical performance: cumulative results of a four-year study with the Objective Structured Clinical Examination

BACKGROUND

The Objective Structural Clinical Examination (OSCE) is an objective method for assessing clinical skills and can be used to identify deficits in clinical skill. During the past 5 years, we have administered 4 OSCEs to all general surgery residents and interns.

METHODS

Two OSCEs (1993 and 1994) were used as broad-based examinations of the core areas of general surgery; subsequent OSCEs (1995 and 1997) were used as needs assessments. For each year, the reliability of the entire examination was calculated with Cronbach's alpha. A reliability-based minimal competence score (MCS) was defined as the mean performance (in percent) minus the standard error of measurement for each group in 1997 (interns, junior residents, and senior residents).

RESULTS

The reliability of each OSCE was acceptable, ranging from 0.63 to 0.91. The MCS during the 4-year period ranged from 45% to 65%. In 1997, 4 interns, 2 junior residents, and 2 senior residents scored below their group's MCS. MCS for the groups increased across training levels in developmental fashion (P < .05).

CONCLUSIONS

Given the relatively stable findings observed, we conclude (1) the OSCE can be used to identify group and individual differences reliably in clinical skills, and (2) we continue to use this method to develop appropriate curricular remediation for deficits in both individuals and groups.

Critical assessment of the head and neck clinical skills of general surgery residents

Head and neck surgery is an important part of general surgery. There is, however, little information about the quality of residents' clinical skills in this important field. In an Objective Structured Clinical Examination (OSCE), residents encounter multiple patients with various clinical problems and are rated by faculty members using objective criteria. This study was undertaken to assess the head and neck surgery skills of a group of general surgical residents. Fifty-one general surgery residents examined the same nine patients with head and neck disease. Faculty members graded each clinical interaction according to preset objective criteria. Both actual (e.g., thyroid nodule, oral cancer follow-up examination) and simulated (e.g., dysphagia) patients were used in the OSCE. The reliability of the examination was assessed by coefficient alpha. The construct validity was determined by a two-way analysis of variance with one repeated measure. The reliability was 0.75 for the clinical examination. Performance varied by level of training: Residents performed at a higher level than interns (p < 0.0001), but overall scores were poor (mean score 55%). Important deficits in skills were identified at all levels of training. It is concluded that more attention should be focused on specific outcome assessments of surgical training programs and on strategies for upgrading the clinical skills of surgical residents.

The reliability of six faculty members in identifying important OSCE items

PURPOSE

To measure the agreement among faculty members about the importance of items on a checklist used to grade an objective structured clinical examination (OSCE) station.

METHODS

Six faculty members rated the importance of 47 items for an OSCE station in which students took the history of a patient with sore throat and hoarseness.

RESULTS

Of the 47 items, the raters independently identified 15 items as very important. The reliability of each individual rater was fair (averaged value of alpha = .63.) The reliability of the mean rating of the six raters was high (alpha = .91).

CONCLUSIONS

The results strongly suggest that when a group of faculty members cooperatively identifies the important items to be included in an OSCE checklist, the reliability of the checklist is superior to one created by a single author.

Late-onset preemptive analgesia associated with preincisional large-dose alfentanil

Few studies using systemic opioids have been adequately designed to demonstrate a preemptive effect. We investigated the preemptive effect of intraoperative large-dose intravenous (I.V.) opioids over a 72-h period after lower abdominal surgery. Thirty-eight ASA physical status I or II patients undergoing abdominal hysterectomy were studied in a prospective, randomized, double-blind design. Group PRE received alfentanil 70 microg/kg over 10 min before surgical incision; Group POST received alfentanil 70 microg/kg over 10 min after incision. Patients received no other intraoperative opioid. Pain was treated in the recovery room with 2-mg I.V. boluses of morphine and was subsequently managed via patient-controlled analgesia (PCA) using morphine sulfate. Visual analog scale pain scores at rest (VAS-R) and on movement (VAS-M) and PCA morphine consumption were recorded for 72 hours. VAS-M and VAS-R scores did not differ at any point, and morphine consumption was similar in both groups over the initial 48 h. Group PRE used significantly less morphine from 48 to 72 h postoperatively (P < 0.02). We conclude that presurgical incisional (i.e., compared with postincisional) large-dose opioid exposure results in a modest, late decrease in postoperative morphine consumption, with no clinical impact on early postoperative pain. Timing of the observed reduction coincides with maximal output of substances implicated in experimental hyperalgesia.

IMPLICATIONS

When given before surgical incision, alfentanil, a short-acting narcotic, was associated with a reduction in morphine requirements 48-72 h after surgery. Brief interventions may have a delayed and sustained impact on pain perception, possibly by reducing mechanisms of sensitization.

Improving residents' clinical skills with the structured clinical instruction module for breast cancer: results of a multiinstitutional study. Breast Cancer Education Working Group

BACKGROUND

The purpose of this study was to determine, in a multiinstitutional setting, the effectiveness of the structured clinical instruction module (SCIM) as an instructional format for surgical residents.

METHODS

The breast cancer SCIM is an abbreviated (3-hour) clinical skills course that places residents in realistic clinical settings. The curriculum encompasses all aspects of breast cancer patient assessment. The SCIM was administered to 137 residents at five institutions. Sixty-six faculty members and 52 patients participated. All participants were surveyed with multiitem questionnaires. The residents were also asked to perform a self-assessment of their skills before and after the SCIM.

RESULTS

The SCIM was delivered at all institutions without difficulty. All participants rated the SCIM highly (from "above average" to "outstanding"). Mean ratings (on a 5-point scale) for the overall effectiveness of the SCIM as an educational format follow: [table: see text] The pretest mean (on a 5-point scale) on the self-assessment was 2.46 ("less than competent"); the posttest mean was 3.54 ("more than competent") (p < 0.0001).

CONCLUSIONS

Residents are acutely aware of their deficiencies in understanding breast cancer. The SCIM is a standardized, reproducible, portable, and effective educational vehicle.

Cancer pain education among family physicians

This study used performance-based testing (objective structured clinical evaluation, OSCE) to evaluate the skills of family physicians in assessing and managing the severe pain of a cancer patient, and evaluated a new method of education about the management of cancer pain. Twenty-four primary care physicians completed a detailed pain assessment of the same standardized cancer pain patient (Part A). A proctor observed the interviews and rated the physicians on a variety of pre-determined items believed to be important for pain assessment. The physicians were then allowed 5 min to answer management questions about the patient's cancer pain (Part B). After reviewing each physician's performance on Parts A and B, the proctor provided immediate feedback and instruction (Part C) on basic principles of cancer pain assessment and management. On average, the primary care physicians asked 52% (+/-4.5%) of the indicated questions of a detailed pain assessment. Performance was poorest in asking about previous pain history, temporal pattern of pain, and pain intensity. Performance on the pain assessment was best for eliciting pain location and pain-relieving factors. Primary care physicians obtained mean scores of 36% (+/-3%) on Part B of the OSCE. Although opioid therapy was frequently prescribed, only 42% of prescriptions were for regular administration. Performance on Parts A and B correlated poorly with years in practice, and older physicians tended to perform a less detailed pain assessment than their younger colleagues. Most physicians enjoyed participating in this instructional formal and believed that the proctor feedback increased the educational value of the module. The results of our study suggest that many family physicians may be inadequate in their clinical assessment and management of cancer pain. Our study supports the need for continuing education in cancer pain management, regardless of years in practice. Further study should evaluate the effects of different educational programs on clinical practice in patient care.

Residents' evaluation of a problem-based learning curriculum in a general surgery residency program

METHODS

To determine residents' satisfaction with problem-based learning and its tutors, to determine how residents prepare for sessions, and to identify the characteristics of both effective sessions and tutors, we analyzed 132 evaluations from 24 residents who completed 1 or more of the 9 cases presented during the first 9 months of our program. The 38-item evaluation questionnaire asked residents to rate tutor characteristics, various aspects of the sessions, and methods used to prepare for the sessions.

RESULTS

Residents were well satisfied with the problem-based learning sessions and with the logistics of our program; they found the overall quality of the tutor more important than that of the case; they valued an active, thought-provoking tutor more than a traditional facilitator; and they most often used standard textbooks to prepare for the sessions.

CONCLUSIONS

Problem-based learning is a practical, enjoyable graduate curricular vehicle when implemented with well-written cases and active tutors.

Ward evaluations: should they be abandoned?

Even in the era of the objective structured clinical examination (OSCE), the predominant method of resident evaluation is the faculty ward evaluation (WE), despite many concerns about its reliability. The aim of this study was to determine the value of the WE as a measurement of clinical competence in terms of both reliability and validity. In a one-year period, surgery faculty members evaluated 72 residents. An average of 7 faculty members evaluated each resident. The evaluation form contained 10 specific performance ratings and an overall evaluation. Inter-rater reliability of the overall performance ratings was calculated by using the intraclass correlation. Validity of the WE was evaluated in four ways. Inter-rater reliability of the overall performance rating was 0.82; the reliability of a single overall rating was 0.39. (1) A discriminant function analysis indicated that residents at advanced levels of training received more positive evaluations than residents at less advanced levels (P < 0.0001). (2) The overall rating was significantly correlated (r = 0.55, P < 0.0001) with the overall score of a concurrent OSCE. (3) A factor analysis showed high correlations among the items, indicating a lack of discrimination between the skills. (4) Overall ratings were insensitive to performance deficiencies. Only 1.3% of the ratings were unsatisfactory or marginal. The WE was sufficiently reliable to estimate the faculty's view of each resident. The fact that the ratings tended to differentiate residents by level of training and that ratings significantly correlated with the OSCE provides strong evidence of their validity. However, factor analysis indicated that the faculty members were making one global, undifferentiated judgment and that these ratings did not identify deficient performance skills. We conclude that ward evaluations have a place in the assessment of residents.

The multidisciplinary structured clinical instruction module as a vehicle for cancer education

BACKGROUND

The Structured Clinical Instruction Module (SCIM) modifies the Objective Structured Clinical Examination (OSCE) for teaching purposes. This study determined the effectiveness of a breast cancer SCIM in enhancing residents' clinical skills.

METHODS

Twenty-five residents, 15 faculty members, and 12 breast cancer patients (simulated and actual) participated in the multistation, multidisciplinary SCIM. Afterward, faculty members, residents, and patients evaluated the SCIM. Residents completed an 18-item self-assessment of their skills before and after the SCIM.

RESULTS

All residents, faculty members, and patients rated the SCIM as either outstanding or above average as an educational experience. The residents' self-assessments of their skills were significantly higher after the SCIM than before.

CONCLUSIONS

This study shows that residents are aware of their deficiencies in breast cancer management. The SCIM provides an excellent format for residents to improve their clinical skills.

The structured clinical instruction module as a tool for improving students' understanding of breast cancer

The Structured Clinical Instruction Module (SCIM) is a novel format for teaching clinical skills. A multidisciplinary SCIM was presented to 30 medical students to improve their understanding of breast cancer. The SCIM consisted of 12 10-minute stations, each covering a different aspect of the diagnosis and management of breast cancer (e.g., history, physical examination, treatment options, mammography, cytology, and pathology). The students rotated through the various stations in groups of three. Nine patients and 14 faculty members participated. At the end of the SCIM, students, faculty, and patients rated their level of agreement (on a five-point scale ranging from "Strongly Disagree" to "Strongly Agree") with statements on a multi-item evaluation questionnaire. All ratings were positive. The students agreed most that the small-group format was an effective instructional method (mean, 4.6). Both students and faculty agreed that the SCIM increased students' clinical skills (mean, 4.4 in both evaluations). Faculty expressed a willingness to participate in future such workshops (mean, 4.6). Patients agreed most strongly that they enjoyed the SCIM (mean, 5.0) and that faculty feedback to students was excellent (mean, 5.0). The SCIM was well received by all participants in this pilot project.

Measuring the ability of residents to manage oncologic problems

BACKGROUND

An OSCE was used to measure the ability of a cohort of residents to manage oncologic problems.

METHODS

Nine oncologic clinical problems were presented to 56 surgical residents. Each problem contained a 5-minute data-gathering period (DGP) and a 5-minute data-interpretation period (DIP). A performance score was determined for each resident for each problem. Reliability was estimated by coefficient alpha; validity, by the construct of experience. Wilks's lambda criterion was used to determine whether training level could be identified by OSCE performance.

RESULTS

The DGP reliability was 0.80; the DIP, 0.49. Senior residents performed significantly better than junior residents (P = 0.0001), who performed significantly better than interns (P = 0.0009). Of the residents, 62% were competent on the DGP, but only 21% on the DIP. Important deficits in knowledge and clinical skills were apparent at all levels of training.

CONCLUSION

The education and evaluation of residents in oncology need improvement.

Residents' management of the symptoms associated with terminal cancer

The principal aim of palliative care is to bring symptomatic relief to patients with progressive disease. Residents graduating from a university general surgery training program should be competent to manage common symptoms associated with advanced cancer. This study used performance-based testing to evaluate the skills of resident physicians in managing common symptoms of a patient with advanced cancer. Thirty-three resident physicians (PGY 1 to 6) were presented with four clinical symptoms of a patient with advanced cancer: (1) nausea and vomiting associated with regular morphine use; (2) lack of appetite in the last weeks of life of a terminally ill patient; (3) constipation associated with codeine analgesia; and (4) dyspnea associated with diffuse lung metastases. The management plan for the symptom problems was evaluated by using a predefined checklist. A significant number of residents showed deficits in the management of common symptoms of advanced cancer. Scheduled dosing of antiemetics was infrequently prescribed for opioid-related nausea and vomiting. Most physicians inappropriately managed lack of appetite by using forced feeding. Opioids were infrequently used in the management of terminal dyspnea. The absence of difference in scores between junior and senior residents suggests that adequate management of the symptoms of terminal cancer is not being effectively taught in postgraduate training programs.

Developing generalists for Kentucky

Since 1985, nearly half of the graduates of the University of Kentucky College of Medicine have chosen generalist careers, even though its students received almost no outpatient ambulatory training in primary care before 1990. This study determined the factors influencing the choice of generalist specialties in the absence of ambulatory training experience. A questionnaire was mailed to the 516 graduates of the classes of 1964 through 1989 who had entered a generalist specialty. A three-way ANOVA with one repeated measure was used to determine whether there were statistically significant differences in the responses of practitioners in the three generalist specialties (family practice, general internal medicine, or general pediatrics). Sufficiently complete responses were received from 187 graduates (116 family practitioners, 40 general pediatricians, and 31 general internists). Many of the physicians who had spent formative years in rural areas were practicing in rural communities. Many respondents had already decided upon a generalist career before entering medical school. Clerkships in internal medicine and pediatrics were an important influence, as was mentor role modeling. For pediatricians, an elective ambulatory care experience was also important. Educational experiences exert meaningful influences on students interested in a generalist career. Formal ambulatory care training experiences, while not critical for the selection of a generalist career, may heighten or confirm interest. Efforts that encourage students from rural communities to enter medical school appear to produce rural physicians.

Cancer pain assessment and management by housestaff

Pain control for cancer patients is a significant problem in health care, and lack of expertise by clinicians in assessing and managing cancer pain is an important cause of inadequate pain management. This study was designed to use performance-based testing to evaluate the skills of resident physicians in assessing and managing the severe chronic pain of a cancer patient. Thirty-three resident physicians (PGY 1-6) were presented with the same standardized severe cancer pain patient and asked to complete a detailed pain assessment. The residents then completed questions related to management of the cancer pain patient. In the cancer pain assessment, residents did well in assessing pain onset (70%), temporal pattern of pain (64%), and pain location (73%). However, only 33% and 45% physicians adequately assessed the pain description and pain intensity, respectively, and assessment of pain-relieving factors, previous pain history, and psychosocial history was done poorly or not at all by 70%, 88%, and 94% of residents. Only 58% of the residents were judged to be competent in this clinical cancer pain assessment. In the cancer pain management section, opioid analgesic therapy was prescribed by 98% of residents, and 91% used the oral route. However, only 18% of prescriptions were for regular use and 88% of residents did not provide analgesics for breakthrough pain. A significant number of graduated physicians were judged to be not competent in the assessment and management of the severe pain of a standardized cancer patient. Opioids and NSAIDs were the analgesics of choice; however, most were prescribed on a PRN basis only. Co-analgesics were rarely prescribed. Few physicians managed persistent, severe cancer pain according to the WHO guideline of increasing the opioid dose. The lack of significant difference in scores between junior and senior residents suggest that adequate cancer pain management is not being effectively taught in postgraduate training programs.

The use of objective structured clinical examination (OSCE) for evaluation and instruction in graduate medical education

This study had two purposes: determining the reliability and validity of the Objective Structured Clinical Examination (OSCE) in assessing performance by trainees at all levels, including medical students and chief residents; and estimating the impact of providing OSCE participants with immediate feedback about their performance. A comprehensive 210-min OSCE was administered to 53 surgical residents and 6 junior medical students. Faculty experts proctored all patient stations and provided immediate feedback to participants after the patient interaction segments (Part A). The participants then answered questions about the patients seen (Part B). The reliability of the OSCE was high (.91), identical to that of a previous resident OSCE with no feedback. The standard error of measurement for both parts was approximately 4%. At the 95% confidence interval, each participant's actual level of clinical performance (Part A) and clinical knowledge (Part B) could be estimated with an error of +/-8%. Participants showed significant differences in clinical performance (Part A, P < 0.01) and knowledge (Part B, P < 0.01) by level of training. Most participants (74%) rated the OSCE as an above average or outstanding educational method. The OSCE is a valid and reliable test of residents' clinical skills. Feedback to participants during the OSCE was positively received and did not perturb test reliability.

Factors influencing medical students' choice of academic medicine as a career

The purpose of this study was to identify the characteristics of physicians who chose academic medicine as a career. A questionnaire was sent to all graduates of the University of Kentucky College of Medicine who held full-time positions in academic medical centers (n = 143). Ninety graduates (63%) returned usable questionnaires. Most of the physicians grew up in urban areas. Seventy-seven percent of the graduates entered academic medicine directly from their residency or fellowship programs. The most important factors cited by respondents as influencing a career choice of academic medicine were an interest in teaching and a belief that their personality and skills suited them to an academic environment. An interest in doing research was not a very important factor. Respondents also indicated why they chose their particular specialty. The two most important factors were the content of the specialty and intellectual stimulation. Most of these physicians (64%) were very satisfied with their careers in academic medicine.

The surgical clerkship: characteristics of the effective teacher

A good relationship between medical students and clinicians is crucial to a positive learning experience. To increase contact between surgical teaching staff and students, a teacher programme was instituted in the problem-based surgical clerkship at the University of Kentucky. This study examined the teacher traits and skills that medical students perceive as distinguishing effective from ineffective teachers. The 312 evaluations collected from students in successive surgical clerkship rotations (87% response rate) were used to determine the characteristics of the effective teacher. Results suggest that students rate increased contact with surgical teaching staff highly and that they value increased mentoring by the staff. The traits of teachers rated highly by students in the surgical clerkship include: being a positive role model, encouraging communication, and being well organized. Comparing data from the 2 years of the clerkship also revealed that providing feedback to staff on their performance as teachers enabled them to improve their instructional skills.

The association between reading time and students' performance in a surgery clerkship

OBJECTIVE

Medical students are expected to acquire a large amount of knowledge in both the basic and clinical sciences by reading. The purpose of this study was to examine the relationship between reading time and students' performance on various objective and subjective evaluative measures.

METHODS

The study examined the reading activities of 80 students in a third-year surgery clerkship. Students spent an average of 16 hours per week in reading activities.

RESULTS

A modest but statistically significant correlation was found between the total amount of time spent in reading and students' performance on an objective standardized clinical examination, a standardized patient encounter, a subjective rating by faculty members, and the total objective grade. Reading time did not correlate with performance on objective measures such as quizzes or the National Board of Medical Examiners examination.

CONCLUSION

Although achievement in the clerkship is associated to a minor degree with reading time, reading time alone is not a sufficient influence on achievement.

The Objective Structured Clinical Examination. The new gold standard for evaluating postgraduate clinical performance

OBJECTIVE

The authors determine the reliability, validity, and usefulness of the Objective Structured Clinical Examination (OSCE) in the evaluation of surgical residents.

SUMMARY BACKGROUND DATA

Interest is increasing in using the OSCE as a measurement of clinical competence and as a certification tool. However, concerns exist about the reliability, feasibility, and cost of the OSCE. Experience with the OSCE in postgraduate training programs is limited.

METHODS

A comprehensive 38-station OSCE was administered to 56 surgical residents. Residents were grouped into three levels of training; interns, junior residents, and senior residents. The reliability of the examination was assessed by coefficient alpha; its validity, by the construct of experience. Differences between training levels and in performance on the various OSCE problems were determined by a three-way analysis of variance with two repeated measures and the Student-Newman-Keuls post hoc test. Pearson correlations were used to determine the relationship between OSCE and American Board of Surgery In-Training Examination (ABSITE) scores.

RESULTS

The reliability of the OSCE was very high (0.91). Performance varied significantly according to level of training (postgraduate year; p < 0.0001). Senior residents performed best, and interns performed worst. The OSCE problems differed significantly in difficulty (p , 0.0001). Overall scores were poor. Important and specific performance deficits were identified at all levels of training. The ABSITE clinical scores, unlike the basic science scores, correlated modestly with the OSCE scores when level of training was held constant.

CONCLUSION

The OSCE is a highly reliable and valid clinical examination that provides unique information about the performance of individual residents and the quality of postgraduate training programs.

The structured clinical instruction module: a novel strategy for improving the instruction of clinical skills

We have previously shown that both medical students and residents demonstrate numerous important deficits when evaluating patients with abdominal complaints. To address these deficits, we implemented a pilot instructional program derived from the Objective Structured Clinical Examination. Fifty third-year medical students were presented with a 1-hr Structured Clinical Instruction Module (SCIM) of five stations, each station addressing a different aspect of the surgical evaluation of the abdomen. Simulated patients were present at two of the stations. Faculty from appropriate disciplines were present at the stations to provide standardized instruction according to predetermined curricular objectives. The medical students evaluated the SCIM for its specific characteristics, and they evaluated each of the five stations for its efficacy in increasing their clinical skills. All the specific aspects of the SCIM were given a rating significantly higher than neutral (P < 0.0001). Students agreed most strongly that the faculty were well prepared for the SCIM and that the faculty were enthusiastic. All of the SCIM stations were given a rating significantly higher than average (P < 0.0001). When compared to a conventional workshop, the SCIM scored significantly higher on all three common evaluation items. The SCIM was very well received by medical students as a format for clinical instruction. This unique modification of the Objective Structured Clinical Examination has potential for teaching important clinical skills that are not consistently mastered within current surgical curricula.

The relationship between faculty ward evaluations, OSCE, and ABSITE as measures of surgical intern performance

BACKGROUND

This study determined the degree to which ward evaluations, the American Board of Surgery In-Training Examination (ABSITE), and an Objective Structured Clinical Examination (OSCE) provide equivalent information about intern performance.

METHODS

Twenty-two general surgery interns completed both the ABSITE and a 17-problem, 35-station OSCE. Faculty members completed several 12-item ward evaluations for each intern. Pearson product-moment correlations were employed to determine the degree of association among the various evaluation measures.

RESULTS

The total OSCE score correlated with both the total ABSITE score and the overall ward evaluations, but the latter two measures did not correlate with each other. The ward evaluations identified the performance of 1 of the 22 interns (5%) as deficient, the ABSITE identified 9 (41%) as deficient in knowledge, and the OSCE 8 (36%).

CONCLUSIONS

In the future, performance-based testing methods such as the OSCE should become more important as an evaluative parameter in assessing the clinical performance of postgraduate surgical trainees.

Demographic, educational, and psychosocial factors influencing the choices of primary care and academic medical careers

PURPOSE

To identify demographic, psychosocial, and educational variables that differentiate physicians who have chosen careers in primary care from those who have chosen academic medicine.

METHOD

Questionnaires were distributed in the spring of 1992 to 704 physicians (546 in primary care practices and 143 in academic medicine) who had graduated from the University of Kentucky College of Medicine, 1964-1991. Mann-Whitney U tests and analyses of variance were used for statistical comparisons.

RESULTS

A total of 336 physicians responded: 246 in primary care and 90 in academic medicine. The primary care physicians tended to come from smaller cities than did the academic physicians (p < .0001). The primary care physicians also had made their career choices earlier than did the academic physicians (p < .0001). For the academic physicians, long-term participation in research, intellectual stimulation, content of specialty, and influence of a mentor or role model were significantly more important factors than they were for the primary care physicians, for whom length of training, direct patient contact, and threats of malpractice suits were significantly more important.

CONCLUSION

The results corroborate the findings of previous studies that suggest that career-choice factors are influenced by admission procedures and curricular structures. The number of graduates choosing careers in either primary care or academic medicine may be increased by increasing their experiences in those fields. Medical schools may be able to use demographic, psychosocial, and curricular factors to fulfill their particular primary mandates, whether they be producing physicians in primary care or in academic medicine.

Sedation for upper gastrointestinal endoscopy: a comparison of alfentanil-midazolam and meperidine-diazepam

The authors studied the efficacy and cost of substituting sedation using midazolam and alfentanil for the existing regimen of diazepam and meperidine in patients requiring upper gastrointestinal endoscopy. Sixty consenting subjects were randomized to receive either meperidine 50 mg with diazepam approximately 90 micrograms.kg-1 (Group D) or alfentanil 250 micrograms with midazolam approximately 50 micrograms.kg-1 (Group M). Endoscope insertion time, patient acceptance, apnoeic or desaturation episodes were noted by a physician observer. Pulse oximetry was used to monitor heart rate and oxygen saturation (SpO2) during endoscopy. Subjects performed four-choice reaction time (4CRT) tests before, 30 and 60 min after endoscopy, and were assessed for nausea or dizziness and their ability to stand and walk. During endoscopy, insertion time was shorter (84 +/- 45 sec vs 122 +/- 83 sec, P < 0.03) and fewer aversive movements occurred (0.4 +/- 0.6 vs. 1.7 +/- 2.4, P < 0.005) in Group M than Group D. No subject in either group suffered any apnoea or prolonged desaturation requiring supplemental oxygen. Irrespective of treatment group, greater decreases in SpO2 (6.1 +/- 3.4% vs 3.6 +/- 2.2% P < 0.001) occurred in subjects > 45 yr of age than in subjects < or = 45 yr. During recovery 4CRT values at 30 min after endoscopy were longer (723 +/- 226 msec vs 594 +/- 139 msec, P < 0.005) in Group M than in Group D but not after 60 min. It was concluded that the small differences in endoscopy conditions and greater sedation during the first 30 min of recovery did not justify the additional cost of using midazolam and alfentnil.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessing surgical residents' and medical students' interpersonal skills

Effective physician-patient interaction is an important part of surgical practice. This study had three goals: (1) to measure the interpersonal skills (IS) of surgical students and residents in structured clinical settings and to determine the reliability of such measurements; (2) to determine the relationship of IS to clinical performance; and (3) to determine the impact of level of training on IS. Twenty third-year medical students and 30 junior-level interns (23 PGY-1s, 7 PGY-2s) interacted with nine actual or simulated patients as part of an objective structured clinical examination. Using a global rating scale, faculty graded both the IS and the organizational skills of the candidates. A two-way analysis of variance indicated significant differences among the three groups of trainees (P = 0.0002) and among the IS scores for each of the nine patient problems (P < 0.0001). Both the PGY-2s and the medical students exhibited significantly better interpersonal skills than did the PGY-1s. The IS scores correlated significantly with the data gathering scores, the data interpretation scores, and the organizational scores. We conclude that faculty measurement of IS is moderately reliable even when a simple global rating scale is used. Overall IS scores were rather poor, particularly in the PGY-1 group. IS were highly correlated with overall objective clinical performance.

Assessing senior residents' knowledge and performance: an integrated evaluation program

BACKGROUND

Surgical residents have traditionally been evaluated by ward evaluations and multiple-choice testing; overall resident performance has seldom been objectively evaluated. We developed a comprehensive evaluation program for senior residents. The purpose of this study was to determine whether the several different assessment methods included in this program provide similar information about senior residents' clinical knowledge and performance.

METHODS

Sixteen senior general surgery residents were evaluated by subjective faculty ward evaluations, a structured oral examination, the American Board of Surgery In-Training Examination, and an objective structured clinical examination (OSCE). The OSCE was divided into two parts: part A required the resident to obtain a directed history or to perform a physical examination; part B required the resident to answer questions about the patient seen in part A.

RESULTS

The various evaluation methods differed in their estimates of clinical competence (ward evaluations rated residents highest; the OSCE, lowest). The American Board of Surgery In-Training Examination correlated with both the structured oral examination and OSCE part B, indicating that all are adequate measures of knowledge. Neither the total OSCE score nor OSCE part A correlated with other measures, but the fact that both are highly reliable suggests that they evaluate different clinical skills. Faculty ward evaluations are inflated and do not correlate with other measures.

CONCLUSIONS

We conclude that developing a comprehensive program for evaluating resident competence is desirable and feasible.

The development and evaluation of new versions of the written examination for the American Heart Association Advanced Cardiac Life Support provider course

STUDY OBJECTIVE

To create new versions of the written, multiple-choice examination used in the American Heart Association (AHA) Advanced Cardiac Life Support course, evaluate their reliability and difficulty, and then design revised versions with improved reliability and of standardized difficulty.

DESIGN

Psychometric evaluation of new versions of the AHA Advanced Cardiac Life Support test and revisions.

SETTING

AHA Advanced Cardiac Life Support courses.

PARTICIPANTS

Candidates for completion of AHA Advanced Cardiac Life Support provider courses in five states.

INTERVENTION

The course content was divided into 11 content areas that were weighted for importance and appropriateness for testing in a multiple-choice format. The weights were used to construct a blueprint for a 50-question, multiple-choice examination. Five versions of the examination were then constructed based on the content blueprint, drawing from new questions and expert revision of previously written questions. Reliability and difficulty were assessed using 915 administrations at five different sites nationwide. The initial test versions differed in their degree of difficulty, which was not explained by demographic factors. The results were used to revise three of the versions to improve reliability and equalize difficulty of the versions.

MEASUREMENTS AND MAIN RESULTS

The final five versions have estimated reliability ranging from Cronbach's alpha of .62 to .86. Mean scores ranged from 87.4% to 89.1%.

CONCLUSION

After field testing and revision, five examinations with acceptable reliability and roughly equal difficulty were constructed. The new examinations test the participants' knowledge of important aspects of resuscitation science and practice based on a blueprint of the course content.

Assessing medical students' and surgery residents' clinical competence in problem solving in surgical oncology

BACKGROUND

We sought to determine the competence of medical students and surgery residents in evaluating clinical problems (using both real and simulated patients) in surgical oncology.

METHODS

Forty-five third-year medical students, 23 first postgraduate year (PGY-1) residents, and seven second postgraduate year (PGY-2) residents were presented with the same four clinical problems (breast evaluation, prostate nodule, colon cancer, and mole evaluation). The two resident groups were presented with two additional patients (breast cancer options and thyroid mass).

RESULTS

Mean performance scores for the problems were generally poor (32-72%); most students and residents failed almost all of the problems. Level of training was of some importance; the overall mean scores of the PGY-2 residents were superior to those of the medical students and the PGY-1 residents (p = 0.049). However, in many areas of information gathering, diagnosis, and management, training level appeared to have no impact. Numerous important performance deficits were identified in all groups.

CONCLUSION

Medical students and surgery residents are not receiving adequate training in diagnosing and treating important problems in surgical oncology.

Knowledge gain in a problem-based surgery clerkship

PURPOSE

To determine the magnitude of students' knowledge gain in a problem-based surgery clerkship and to identify the relationship of this gain to measures of clinical performance.

METHOD

Third-year students in a problem-based surgery clerkship at the University of Kentucky College of Medicine in 1990-91 were evaluated by a comprehensive set of objective measures: surgery subject examinations of the National Board of Medical Examiners (NBME) given as pretest and posttest to assess knowledge gain, two multiple-choice quizzes, a modified-essay examination, a standardized-patient examination, and an objective structured clinical examination (OSCE). The students were also evaluated by faculty tutors and preceptors and by their peers. NBME data were available for 66 students, and data were available on the other measures for 42 students. Statistical analysis involved two-way analysis of variance, single group t-test, Pearson correlations, and partial correlations.

RESULTS

The students' knowledge gain was statistically significant. The posttest mean score did not differ significantly from the national candidate mean of 500. All but two of the other knowledge and performance measures (the preceptor and tutor evaluations) correlated significantly with the knowledge gain score. The highest correlations were for peer evaluations, the standardized-patient examination, and the modified-essay examination. The overall reliability of the eight measures of student knowledge and performance was .81; deleting any measure, except the preceptor evaluation, lowered the reliability below the benchmark of .80.

CONCLUSION

The results suggest that a highly significant knowledge gain occurred during the problem-based clerkship and that this gain in knowledge was closely related to improved clinical performance.

Defining the surgical personality: a preliminary study

Noting that noncognitive factors may be more predictive of success in a medical career than is intellectual ability or cognitive performance, we undertook a study to determine whether a surgical personality exists and to delineate the temperament and personality traits that contribute to its definition. The Krug Adult Personality Inventory, the Strelau Temperament Inventory, and Barclay's adjective checklist were administered to 110 physicians, 35 in a "controllable lifestyle" specialty, 28 in primary care, and 47 in surgery or a surgery subspecialty. In addition, participants completed a stress inventory. Results showed that surgeons form a distinct and homogeneous group based on temperament and personality traits. We suggest that noncognitive factors can be of use to medical educators in the selection, counseling, training, and evaluation of medical personnel.

Performance of the vascular physical examination by residents and medical students

PURPOSE

This study uses an objective structured clinical examination to evaluate the performance and interpretation of the vascular physical examination by interns and medical students.

METHODS

A patient with lower extremity arterial occlusive disease findings was examined by 20 third-year students (M3), 23 physicians entering surgical internship (PGY1), and 7 individuals completing internship (PGY2). The test consisted of two sections: part A evaluated the individuals' ability to perform a pulse examination (data gathering); part B evaluated the interpretation of the physical examination findings (data interpretation). National Board of Medical Examiners Part II examination results were obtained for 84% of participants.

RESULTS

All groups performed poorly, with overall correct percent scores being 43% (M3), 39% (PGY1), and 62% (PGY2). PGY2s performed significantly better than M3s or PGY1s (p = 0.0002). No statistical difference was noted between M3 and PGY1 scores. Overall, data gathering skills were significantly better than data interpretation skills (51% vs 37%, p = 0.0001). National Board of Medical Examiners Part II scores did not vary substantially among groups.

CONCLUSIONS

Interns and medical students demonstrated considerable inaccuracy in both data gathering and data interpretation. A modest improvement was observed in individuals tested at the end of the internship year. This study suggests that increased attention should be directed toward instructing surgical residents and students how to perform an accurate peripheral vascular physical examination and how to interpret its significance.

Use of an Objective Structured Clinical Examination (OSCE) to measure improvement in clinical competence during the surgical internship

BACKGROUND

Traditional ward ratings and multiple-choice tests do not reliably assess clinical competence. This study determined the reliability of the Objective Structured Clinical Examination (OSCE) and its sensitivity in detecting the performance gains and deficits in surgical interns.

METHODS

A comprehensive 35-station OSCE was administered to 23 incoming interns and seven outgoing interns. The OSCE comprised 17 two-part clinical problems, relying primarily on actual or simulated patients. The reliability of the examination was assessed by coefficient alpha. Significant differences in performance between the two intern groups, between parts A and B, and among the 17 problems were determined by a three-way ANOVA: OSCE performance was also correlated with National Board of Medical Examiners Part II scores.

RESULTS

The reliabilities of part A, part B, and parts A and B combined were 0.72, 0.70, and 0.82, respectively. Overall, the outgoing interns performed significantly better than the incoming interns: 58% +/- 1% mean OSCE score versus 47% +/- 1% (p = 0.0001). The 17 clinical problems differed significantly in difficulty; major performance deficits were seen in both groups of trainees. The correlation of OSCE scores with National Board of Medical Examiners Part II scores was not significant (r = 0.11, p = 0.633).

CONCLUSIONS

We conclude that the OSCE is an innovative, reliable tool for evaluating resident competence. Although outgoing interns performed better than did incoming interns, the OSCE scores clearly indicated major performance deficits in all interns.

Influencing the attitudes of medical students toward diabetes. Results of a controlled study

OBJECTIVE

To determine the effect of two educational interventions on the diabetes-related attitudes of medical students.

RESEARCH DESIGN AND METHODS

We studied 67 junior and senior medical students who were participating in the University of Michigan Medical School's Family Practice elective clerkship. Students were assigned to one of two interventions. The first was a 1-wk living-with-diabetes behavioral simulation that involved injections, blood glucose monitoring, diet, exercise, and record keeping. The second intervention involved reading an autobiography about living with diabetes and viewing a videotape about the psychosocial impact of diabetes.

RESULTS

No differential impact was found between the two interventions. However, both interventions were followed by a modest positive change in the attitudes of the medical students (which were very positive to begin with) toward the importance of patient autonomy and the value of the team approach to diabetes care. The attitude gains persisted at follow-up for patient autonomy but returned to baseline for team care.

CONCLUSIONS

This study suggests that these two educational interventions resulted in modest increases in the already positive attitudes of medical students toward the importance of patient autonomy and team care in diabetes. However, because the study did not include a group that received no treatment, we cannot be certain on this point. The attitude gain related to team care did not persist at follow-up. These findings are consistent with classical attitude research, which suggests that attitudes are sensitive to influences such as these interventions, but that attitude changes may not persist when those influences are changed or withdrawn. We were not able to find a differential impact between the two interventions and suspect that the general nature of the DAS used as the dependent measure may not have been sensitive enough to capture such a differential impact.

Changes in the patterns of specialties selected by high and low academic performers before and after 1980

BACKGROUND

The goal of this study was to examine whether recently observed changes in the distribution of medical school graduates' choices are linked to level of academic achievement, graduation year, or both.

METHOD

The authors studied the specialty selections made by two groups of graduates of the University of Kentucky College of Medicine: 319 who were elected to Alpha Omega Alpha and 276 who ranked academically in the bottom 10% of their classes. They also divided the groups into two time frames: 1964-1979 and 1980-1991. Two-way factorial analyses of variance compared the distributions of specialty selections according to time frame and to academic group.

RESULTS

Significantly higher percentages of students in the low-achievement group selected primary care specialties (F = 14.76, p < .001), and this difference between the academic groups increased in recent years: 67% versus 41% in 1980-1991 compared with 53% versus 46% in 1964-1979.

CONCLUSIONS

The specialty options most readily available to academically low-achieving medical school graduates are narrowing. Low achievers may be funneled into primary care simply because they cannot compete for other specialties. The authors recommend that: (1) recruitment and selection into primary care specialties should be made only after each candidate has been assessed over a broad range of cognitive and noncognitive factors and (2) academically low-ranking graduates should not end up in primary care specialties simply because no other specialty options are available to them.

The ongoing development of a problem-based surgery clerkship: year three

The third-year clerkship at one college of medicine was modified to reflect an emphasis on adult learning principles and life-long learning habits. Problem-based learning was selected as the educational method, and the development of a cognitive knowledge base, clinical problem-solving skills, and appropriate clinical skills was stressed. At a yearly faculty education retreat, strengths and weaknesses of the clerkship were discussed. As a result of this meeting, several changes were made in the clerkship, including additional stress on students' usage of the medical library and computerized databases, a tutor development program, the addition of expert resource sessions, and more emphasis on students' development of clinical skills through a preceptor program. A comprehensive evaluation program designed to support the educational goals of the clerkship is in place. The major challenge of the program remains the proper synchronization of curricular, clinical, and student self-study activities essential for an ideal learning experience.

Undergraduate surgical education for the twenty-first century

This article addresses the problems associated with current undergraduate surgical education and discusses the requirements necessary for its improvement during the third and fourth years of medical school. It asserts that, coincident with the emphasis on faculty research and publication and expanded resident patient care duties, teaching, particularly medical student teaching, has assumed a very low priority. Third-year medical students are attached to surgical teams, where their education is haphazard and disorganized. Furthermore, because any teaching that occurs is teacher oriented rather than student centered, knowledge is accumulated passively and is not well retained. Traditional evaluation using shelf multiple choice examinations and ward ratings by residents and faculty may provide inaccurate assessments of the students' performance. The undergraduate surgical education program should be directed by a faculty member who has been grounded in educational techniques and research and supported by a department chairman committed to bettering the program. In the clerkship, medical students should be assigned to faculty rather than to services and should be presented problems that require solution. Students also should be provided with the resources to solve the problems and should be given sufficient time to solve them. Some operating room experience and bedside teaching should occur during the clerkship. A variety of evaluation and testing methods based on the learning objectives of the clerkship should be used. Third-year students should not be promoted until they have demonstrated their acquisition of appropriate knowledge and skills.(ABSTRACT TRUNCATED AT 250 WORDS)

Problem-based learning: an effective educational method for a surgery clerkship

Problem-based learning (PBL) has been implemented during the clinical years in a few medical schools. The purpose of this study is to determine whether PBL provides a better education than traditional methods. Students in the first and third rotations (n = 42) went through the traditional clerkship, which utilized Socratic teaching (SI), while students in the second and fourth rotations (n = 36) were taught by the PBL method. Two performance measures were used to assess clerkship effectiveness. One was a modified essay examination (MEE) administered as part of the departmental evaluation. The other was the NBME-II exam and its surgery subsection NBME-II-S. The MEE was designed to measure six dimensions of the problem-solving process. The NBME-II was utilized to measure knowledge. Unpaired t tests were used to identify statistically significant group differences. The PBL group performed significantly better on two MEE dimensions: (1) differential diagnosis formation (PBL, 92.5 +/- 0.8; SI, 89.1 +/- 0.5; P < 0.01) and (2) interpretation of clinical data (PBL, 93.3 +/- 0.6; SI, 91.6 +/- 0.4; P < 0.03). A third dimension, ordering appropriate lab and diagnostic studies, approached significance (P = 0.057), and the PBL group performed better. On the NBME-II there was not a significant difference between the two groups. However, the trend (P = 0.059) was for the PBL group to score higher on the NBME-II-S (PBL mean: 502 +/- 15; SI mean: 468 +/- 12). When overall achievement was controlled for, the PBL group performed significantly better than the SI group (P = 0.046) on the NBME-II-S.(ABSTRACT TRUNCATED AT 250 WORDS)

Controversial beliefs about diabetes and its care

OBJECTIVE

The purpose of this study was to identify specific beliefs that differentiate health-care professionals whose attitudes toward diabetes agreed most strongly with a group of national diabetes experts from those whose attitudes disagreed most strongly.

RESEARCH DESIGN AND METHODS

The sample for this study included 271 physicians, 834 nurses, and 546 dietitians who completed a Diabetes Attitudes Survey. The sample included specialists in diabetes care and nonspecialists. Controversial beliefs about diabetes and its care were determined by comparing the beliefs of the 10% of the sample whose attitudes were most concordant (with the national panel) with the beliefs of the 10% of the sample whose attitudes were the most discordant. Ten beliefs met the criteria for being defined as controversial.

RESULTS

The most controversial beliefs concerned whether the patient or the physician should be the primary decision maker in diabetes care, the meaning of patient noncompliance, and the seriousness of non-insulin-dependent diabetes mellitus. The 10% of the sample with the most discordant attitudes contained a disproportionately large number of physicians, nonspecialists in diabetes, and health-care professionals who had been in practice longer than the other members of the sample.

CONCLUSIONS

This study identifies some important differences in beliefs between younger health-care professionals who specialize in diabetes and older nonspecialists. Such beliefs should be addressed in continuing education programs with the aim being to foster the widespread adoption of a contemporary approach to diabetes care.

Perceived effectiveness, cost, and availability of patient education methods and materials

To determine the efficacy of and need for patient education methods and media, a needs assessment was sent to 816 members of the American Association of Diabetes Educators. Respondents (n = 325, 40%) included 62% RNs, 36% RDs, 1% other; 62% CDEs. Their mean number of years experience in diabetes education was 8.5, and 99% routinely provided patient education. Respondents indicated that videotapes and slide tapes were the most educationally effective media and books and audiotapes were the least effective. Booklets and videotapes were the most cost-effective and computer-assisted instruction the least effective. While respondents perceived one-to-one counseling, skills training, and diabetes content sessions to be the three most educationally effective methods, support groups and large and small discussion groups were seen as the three most cost-effective educational methods. Among nine potential barriers to quality patient education listed, educators rated lack of third-party reimbursement as a major barrier most frequently and national availability of quality education materials as a barrier least frequently.