Applicant Experience in Communication With Residency Programs After the Introduction of Program Signaling

OBJECTIVE

Examine the applicant experience after introduction of program signaling for the 2023 obstetrics and gynecology (OBGYN) residency application cycle.

DESIGN

Responses to an online survey of OBGYN applicants participating in the 2023 match who participated in residency program signaling were compared to responses from a similar survey conducted in 2022. Demographic information included personal and academic background and how applicants and advisors communicated with programs. Numbers of applications and interviews, second look visits, away rotations, manner of contact, and timing of communication was compared. Statistical analysis included ANOVA for interval data, and χ2 and Kruskal-Wallis tests for categorical data.

RESULTS

A total of 711 of 2631 (27%) applicants responded in 2022 and 606 of 2492 (24.3%) responded in 2023. Approximately 2/3 of gold signals and 1/3 of silver signals led to an interview. There was no change in number of applications or interviews per applicant, but there was a broader distribution of interviews per applicant in 2023. Applicants in 2023 were less likely to engage in preinterview communication or do an away rotation to indicate interest in a program. There was decreased communication between applicants and programs after signaling was introduced. Informal communication continued to differ by racial and medical school background. Applicants from DO programs and international medical graduates (IMG) had more communication with programs than MD applicants but received fewer interview invitations. Fewer Black and Latin(x)/Hispanic applicants had faculty reach out to residency programs on their behalf compared to White and Asian applicants. There were differences in the number of interviews received based on racial and ethnic identity.

CONCLUSIONS

In the first year after implementation of program signaling, there was a decrease in preinterview communication and a broader distribution of interviews among applicants. Further efforts to create standard means of program communication may help to begin leveling the uneven playing field for applicants.

Knowledge management tools and mechanisms for evidence-informed decision-making in the WHO European Region: a scoping review

BACKGROUND

Knowledge management (KM) emerged as a strategy to promote evidence-informed decision-making. This scoping review aims to map existing KM tools and mechanisms used to promote evidence-informed health decision-making in the WHO European Region and identify knowledge gaps.

METHODS

Following the Joanna Briggs Institute (JBI) guidance for conducting scoping reviews, we searched Medline, PubMed, EMBASE, the Cochrane library, and Open Grey. We conducted a descriptive analysis of the general characteristics of the included papers and conducted narrative analysis of the included studies and categorized studies according to KM type and phase.

RESULTS

Out of 9541 citations identified, we included 141 studies. The KM tools mostly assessed are evidence networks, surveillance tools, observatories, data platforms and registries, with most examining KM tools in high-income countries of the WHO European region. Findings suggest that KM tools can identify health problems, inform health planning and resource allocation, increase the use of evidence by policymakers and stimulate policy discussion.

CONCLUSION

Policymakers and funding agencies are called to support capacity-building activities, and future studies to strengthen KM in the WHO European region particularly in Eastern Europe and Central Asia. An updated over-arching strategy to coordinate KM activities in the WHO European region will be useful in these efforts.

Supporting Medical Education Innovation: Evaluation of a Grants Initiative

PROBLEM

Medical education must evolve to meet the changing needs of patients and communities. Innovation is a critical component of that evolution. As medical educators pursue innovative curricula, assessments, and evaluation techniques, the impact of innovations may be limited by minimal funding. The American Medical Association (AMA) Innovation Grant Program, launched in 2018, seeks to address the gap in funding and stimulate educational innovation and research in medical education.

APPROACH

In 2018 and 2019, the Innovation Grant Program targeted innovation in content areas including health systems science, competency-based medical education, coaching, learning environment, and emerging technology. The authors reviewed the content of applications and final reports for the 27 projects completed during the first 2 years of the program. They also noted measures of success (completion of project, achievement of grant objectives, development of transferrable educational product, dissemination).

OUTCOMES

In 2018, the AMA received 52 submissions and funded 13 proposals, dispersing $290,000 ($10,000 and $30,000 grants). In 2019, the AMA received 80 submissions and funded 15 proposals, dispersing $345,000. Among the 27 completed grants, 17 (63%) supported innovations related to health systems science. Fifteen (56%) were used to create educational products that could be shared, such as new assessment tools, curricula, and teaching modules. Five grant recipients (29%) published articles and 15 (56%) presented at national conferences.

NEXT STEPS

The grant program advanced educational innovations, particularly in health systems science. The next steps will involve examining the long-term outcomes and impact of the completed projects on medical students, patients, and the health system; the professional development of the grantees; and the adoption and dissemination of the innovations.

Sphingolipidoses in Morocco: Chemical profiling for an affordable and rapid diagnosis strategy

Sphingolipidoses are a group of metabolic diseases in which lysosomal hydrolases dysfunction disrupt normal sphingolipids' metabolism, leading to excess accumulation in cellular compartments and excretion in urine. These pathologies represent a significant burden among Moroccan population, for which an easy access to enzymatic assays and genetic tests is not guaranteed. Parallel analytical methods thus have to be developed for preliminary screening. In this study, 107 patients were addressed to the metabolic platform of the Marrakesh Faculty of Medicine for diagnosis confirmation. Thin-Layer Chromatography was used as a first step to perform chemical profiling of the patients' urinary lipids, allowing 36% of the patients to be efficiently oriented towards the adequate enzymatic assay. UPLC-MS/MS analyses of urinary sulfatides excreted in urines patient had been used to control the reliability of TLC analysis and to obtain more accurate information related to the sulfatides isoforms. This analytical process combining TLC with UPLC-MS/MS has enabled rapid and appropriate patient management in a reduced time and with reduced resources.

Developing Master Adaptive Learners: Implementation of a Coaching Program in Graduate Medical Education

n/a

Coaching models, theories, and structures: An overview for teaching faculty in the emergency department and educators in the offices

Coaching is rapidly advancing in medical education as a relational process of facilitating sustainable change and growth. Coaching can support learners in emergency medicine at any stage by improving self-reflection, motivation, psychological capital, and goal creation and attainment. Different from the traditional models of advising and mentoring, coaching may be a new model for many educators. An introduction to key coaching concepts and ways they may be implemented in emergency medicine is provided. Experienced coaches employ a diverse array of models and techniques that may be new to novice coaches. This article summarizes a variety of coaching models, theories, and content areas that can be adapted to a coachee's needs and the situational context-be it the fast-paced emergency department or the faculty member's office.

Medical Trainees Comfort and Confidence in Providing Care to Arab and Muslim Patients at a Large Academic Medical Center

PHENOMENON

There are currently 3.5 million Americans of Arab descent and 3.45 million Muslims living in the United States. These rapidly growing populations face significant health disparities, which is likely in part due to the lack of culturally competent physicians trained to treat these populations. While the Institute of Medicine calls for cross-cultural training for all providers, it is not clear if this need is being met. The purpose of this study is to examine medical trainees' current level of cultural training and whether this corresponds to confidence in caring for Arab and Muslim patients.

APPROACH

The authors created an anonymous survey that was distributed via email to medical students and residents at Michigan Medicine between January and March 2020. Questions included trainees' comfort and confidence level in caring for Arab and Muslim patients, as well education received on this topic.

FINDINGS

Results showed that 41% of respondents were confident in their ability to take a history from an Arab patient immigrated to the U.S. Additionally, 55% of non-Muslim participants reported that they felt comfortable in caring for fasting patients, while only 24% felt confident in their ability to answer patient questions about fasting. Approximately half of respondents felt confident in their ability to examine an Arabic-speaking woman (47%) or woman wearing a hijab (49%). The majority of respondents had not received any training or education in the care of Arab patients (64%) or fasting patients (81%).

INSIGHT

Medical trainees at one large academic medical center in the state with the second largest Arab-American population, and one of the largest populations of Muslim-Americans lack comfort and confidence in providing culturally competent care for Arab and Muslim patients. Education of trainees about Arab and Muslim health should be implemented into the curriculum to optimize care delivered to this patient population.

The foot external rotation above-knee (FERAK) brace versus the Denis Browne brace for management of idiopathic clubfoot following Ponseti casting: a randomized controlled trial

PURPOSE

To compare the foot external rotation above-knee (FERAK) brace and the Denis Browne boot (DBB) brace in terms of relapse prevention and parents' compliance after successful correction with Ponseti casting.

METHODS

A single-centre, randomized controlled study was conducted between 2016 and 2020. A total of 60 feet in 38 patients with idiopathic clubfoot initially corrected with the Ponseti method were included. They were randomized into two equal groups: the FERAK group and the DBB group. The primary outcome was the efficacy in maintaining correction measured by the Pirani score. The secondary outcomes were parents' compliance and complications (e.g., relapses, skin complications).

RESULTS

The follow-up period was 24 months for each patient. The mean final Pirani score was 0.42 ± 0.76 in the FERAK group and 0.57 ± 0.82 in the DBB group. This difference was statistically insignificant (p-value = 0.411). Regarding parents' compliance in the FERAK group, 86.7% of parents had good and intermediate compliance while 13.3% had bad compliance. In the DBB group, 66.7% had good and intermediate compliance while 33.3% had bad compliance. This difference was also statistically insignificant (p-value = 0.118).

CONCLUSION

Both braces achieved good comparable outcomes after Ponseti casting. However, the FERAK brace yielded slightly better parents' compliance with a less recurrence rate.

Medical student and resident perceptions when working together in resident continuity clinics

BACKGROUND

Resident continuity clinics (RCCs), where residents see patients largely independently, is a common requirement for residency programs in the USA. Students often participate in these clinics but it is unknown how this effects resident learning or student satisfaction.

OBJECTIVE

This study aims to describe effects on the learning environment when students and residents work together in an RCC.

DESIGN

Separate surveys were administered to residents and students working at St. Joseph Mercy Hospital (SJMH) in Ann Arbor, Michigan, from 2016-2018.

RESULTS

Response rates were 79/116 (68.1%) for students and 21/24 (87.5%) for residents. A one-sample Wilcoxon signed rank test was used to test whether most five-level Likert-type scale responses were 'agree' or 'strongly agree.' Of medical students, 88.6% enjoyed working with residents (p < 0.001) with 60.8% indicating residents were effective teachers (p < 0.001). The majority of residents (85.7%) were neutral, agreed, or strongly agreed that they enjoyed working with students (p < 0.001). However, 61.9% of residents believed they were too busy to be effective teachers (p < 0.001).

CONCLUSIONS

Both residents and students positively viewed their interactions in RCCs. Although most students felt residents were effective teachers, most residents worried about their ability to balance clinical care and teaching responsibilities.

Coaching in undergraduate medical education: a national survey

Background: Evidence to support coaching in medical education has grown over the past decade leading educators to search for resources to aid the development of their own coaching programs. A sample of medical schools in the USA were surveyed to describe coaching programs to assist other institutions in the development and implementation of programs.Methods: Participants representing 32 medical schools attending a coaching conference in October 2018 were surveyed via email regarding their undergraduate medical education (UME) coaching programs. The 19-item instrument contained questions on program demographics, program characteristics, coach characteristics, coach training and coach assessment and program evaluation.Results: The response rate was 100% (32/32 programs). Nearly all respondents had a coaching program (53%, 17/32) or were developing one (44%, 14/32) with the majority being implemented in the past five years (82%, 14/17). Professional identity formation (80%, 20/25), professionalism (76%, 19/25), and academic performance (76%, 19/25) were the most commonly identified programmatic goals. The majority of coaches (64%, 16/25) received between 5-25% full time equivalent effort to support their role. Coaches did not formally assess students in any domain at most programs (84%, 21/25) or directly observe their students clinically (76%, 19/25). The majority of programs had formal coach training (88%, 22/25).Conclusion: These results demonstrate that coaching is being used to improve performance, professionalism, and professional identity formation in UME. This sample of coaching programs informs the discussion of coaching in medical education as educators strive to implement effective coaching programs.

Stepping Back: Re-evaluating the Use of the Numeric Score in USMLE Examinations

There are increasing concerns from medical educators about students' over-emphasis on preparing for a high-stakes licensing examination during medical school, especially the US Medical Licensing Examination (USMLE) Step 1. Residency program directors' use of the numeric score (otherwise known as the three-digit score) on Step 1 to screen and select applicants drive these concerns. Since the USMLE was not designed as a residency selection tool, the use of numeric scores for this purpose is often referred to as a secondary and unintended use of the USMLE score. Educators and students are concerned about USMLE's potentially negative influence on curricular innovation and the role of high-stakes examinations in student and trainee well-being. Changing the score reporting of the examinations from a numeric score to pass/fail has been suggested by some. This commentary first reviews the primary use and secondary uses of the USMLE scores. We then focus on the advantages and disadvantages of the currently reported numeric score using Messick's conceptualization of construct validity as our framework. Finally, we propose a path forward to design a comprehensive, more holistic review of residency candidates.

Academic coaching: Insights from the medical student's perspective

Purpose: With the growing recognition of the role of coaching in competency-based medical education, many medical education training programs are investing significant resources into developing coaching programs. However, there is a lack of rigorous research on academic coaching programs in medical education and recommended coaching practices are based on expert opinion without incorporating the student perspective. The aim of this study was to investigate factors that affect a students' perception of a successful coaching experience.Materials and method: This was a qualitative study performed in November 2018 at a medical school in the United States with a formal coaching program. Appreciative inquiry was the theoretical framework used to develop the question guide. The authors facilitated two focus groups and then used Colaizzi's phenomenological analysis approach to analyze the transcripts.Results: A total of 21 students participated in the focus groups. The analysis revealed four themes that describe students' perceptions of successful coaching experiences: coach attributes, relational skills, coaching skills, and utilization of coaching. Each of these themes had specific dimensions.Conclusions: The findings from this study illuminate the student stakeholder perspectives on successful coaching relationships, and should be considered when developing a coaching program and faculty development.

The decline in attitudes toward physician-nurse collaboration from medical school to residency

While interprofessional collaboration is a critical aspect of optimal patient care, practicing physicians often have sub-optimal attitudes regarding the importance of collaboration with their nursing colleagues. The impact of clinical training on medical students' and residents' attitudes toward physician-nurse collaboration has not been investigated. The primary goal of our study was to examine if learners at different stages in their medical training had more or less favorable attitudes regarding interprofessional collaboration (IPC). A secondary goal was to compare residents in procedural versus non-procedural specialties to determine if attitudes toward IPC varied by specialty type. Third-year medical students and residents at a large public university completed the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration. Student (n = 129) and resident (n = 292) scores were compared using Student's t-tests. Resident responses were further analyzed by specialty type. Students' perceptions of the physician-nurse relationship were significantly more favorable than the views of residents, particularly in the "Authority" and "Responsibility" domains. Residents in procedural specialties had less favorable attitudes toward physician-nurse collaboration than those in non-procedural specialties. Our findings highlight the importance of developing effective interventions for improving interprofessional collaboration during medical training.

Identifying Medical Student Mistreatment in the Obstetrics and Gynecology Clerkship

OBJECTIVE

To characterize the mistreatment identified within the University of Michigan's Obstetrics and Gynecology (Ob/Gyn) clerkship and compare the rates of mistreatment to that of other clerkships in an effort to improve the learning environment.

DESIGN

This is a retrospective cohort study looking at multiple sources of data from 2015 to 2018 about student mistreatment including end-of-rotation and teaching evaluations completed by students, as well as an online reporting system available to medical students. For evaluations, students were asked to rate their agreement with statements on a 5-point Likert scale (1 = strongly disagree, to 5 = strongly agree). Narrative comments were also solicited and evaluated.

SETTING

University of Michigan Medical School and Michigan Medicine Ob/Gyn Department, Ann Arbor, Michigan.

PARTICIPANTS

A total of 513 students rotated through the Ob/Gyn clerkship between 2015 and 2018 and were asked to complete evaluations.

RESULTS

Five hundred and five of the 513 students completed evaluations between 2015 and 2018. In response to the statement, "Students are treated in a professional/respectful manner in this clerkship," the Ob/Gyn clerkship's mean scores on a 5-point scale were 4.45 (in 2015-2016), 4.52 (in 2016-2017), and 4.27 (in 2017-2018). These means, as well as the means to 3 other professionalism questions, were lower than the range of 4.42 to 4.84 for all other third-year clerkships over this time. The mean scores were also lower for Ob/gyn when compared to the Surgery clerkship. A total of 32 narrative comments were submitted by students between 2015 and 2017 related to mistreatment or unprofessional behavior. Frequent themes included students being treated as "stupid" or discouraged from asking questions (8 comments), being treated in an unprofessional manner by staff (7 comments), feeling ignored or marginalized by faculty (4 comments), and faculty unprofessional behavior toward others (4 comments).

CONCLUSIONS

Students on the Ob/Gyn clerkship reported a higher rate of mistreatment compared to other clerkships. Efforts are being made by the Ob/Gyn department to communicate these data on mistreatment to educators in order to improve the Ob/Gyn culture and learning environment for medical students.

Engaging Medical Students in Leadership Development

Leadership development plays a critical role in preparing collaborative, systems-based physicians. Medical schools across the globe have dedicated significant effort towards programming for medical student leadership development. Students report a variety of existing leadership opportunities, ranging from formal didactics to leadership positions within the community. Students identify lack of time, funding, and the hierarchy of medicine as significant barriers for engaging in leadership opportunities. Students favor a formal leadership curriculum coupled with hands-on opportunities to practice leadership skills. In order to train medical students to be engaged physician leaders, it is imperative to foster practical opportunities for leadership development.

Engaging Medical Students in Leadership Development

Leadership development plays a critical role in preparing collaborative, systems-based physicians. Medical schools across the globe have dedicated significant effort towards programming for medical student leadership development. Students report a variety of existing leadership opportunities, ranging from formal didactics to leadership positions within the community. Students identify lack of time, funding, and the hierarchy of medicine as significant barriers for engaging in leadership opportunities. Students favor a formal leadership curriculum coupled with hands-on opportunities to practice leadership skills. In order to train medical students to be engaged physician leaders, it is imperative to foster practical opportunities for leadership development.

Patient Perspectives on Language Discordance During Healthcare Visits: Findings From the Extremely High-Density Multicultural State of Qatar

Reducing language and cultural barriers in healthcare are significant factors in resolving health disparities. Qatar's rapidly growing multicultural population presents new challenges to the healthcare system. The purpose of this research was to explore patients' perspectives about language discordance, and the strategies used to overcome language barriers during patients' visits. Participants were recruited and interviewed from four language groups (Arabic = 24, English = 20, Hindi = 20, and Urdu = 20), all of whom were living in Qatar and utilizing Hamad General Hospital-Outpatient Clinics as a source of their healthcare services. Using qualitative analysis procedures, relevant themes and codes were generated and data analyzed using Atlas-ti. As for results, most participants had experienced or witnessed language barriers during their outpatient clinics visits. Participants essentially were unfamiliar with professional medical interpreters and described their adaptive solutions, for example utilizing incidental interpreters, stringing together fragments of multiple languages, and using body language. Those not speaking mainstream languages of Hamad General Hospital (English and Arabic) were more vulnerable to health disparities due to language barriers. Despite the patient impetus to do something, patient-reported adaptive strategies could compromise patients' safety and access to quality healthcare. Polices tackling the language barrier need to be reviewed in Qatar's multicultural healthcare system and similar settings.

Improving the medical school-residency transition

BACKGROUND

In response to calls to improve the continuum between undergraduate and graduate medical education, many medical schools are creating electives designed to prepare students for residency training. There is a need for data that link improvements from these residency preparation courses to residency itself. Data is needed that links improvements from these residency preparation courses to residency OBJECTIVE: To examine senior medical student performance on the Association of Professors of Gynecology and Obstetrics (APGO) Preparation for Residency Knowledge Assessment before and after an obstetrics and gynaecology residency preparation elective, and to determine whether the knowledge improvements persisted to the start of the residency.

METHODS

All 13 students enrolled in the course completed the APGO knowledge assessment on the first and last day of the elective. Three months later, the students were asked to re-take the assessment immediately prior to the start of their residency.

RESULTS

There was improvement in mean scores from the pre-test score of 66.4 per cent to the post-test score of 77.4 per cent. At the time of the pre-test, three of the 13 students (23%) had passing scores (70% or greater), and at the time of the post-test, 11 of the 13 (85%) had passing scores. Nine of the 13 students (69%) completed the APGO knowledge assessment immediately prior to the start of their residency. Those nine students had a mean pre-residency score of 76.4 per cent. Eight of the nine students (89%) passed the pre-residency test.

CONCLUSIONS

Our data support the value of residency preparation electives for improving knowledge, and suggest that senior medical school electives can help to bridge the continuum between undergraduate and graduate medical education.

Evaluation of a simulation-based curriculum for implementing a new clinical protocol

OBJECTIVE

To evaluate the implementation of a new clinical protocol utilizing on-unit simulation for team training.

METHODS

A prospective observational study was performed at the obstetrics unit of Von Voightlander Women's Hospital, Michigan, USA, between October 1, 2012 to April 30, 2013. All members of the labor and delivery team were eligible for participation. Traditional education methods and in-situ multi-disciplinary simulations were used to educate labor and delivery staff. Following each simulation, participants responded to a survey regarding their experience. To evaluate the effect of the interventions, paging content was analyzed for mandated elements and adherence to operating room entry-time tracking was examined.

RESULTS

In total, 51 unique individuals participated in 12 simulations during a 6-month period. Simulation was perceived as a valuable activity and paging content improved. Following the intervention, the inclusion of a goal time for reaching the operation room increased from 7% to 61% of pages and the proportion of patients entering to operating room within 10 minutes of the stated goal increased from 67% to 85%.

CONCLUSION

The training program was well received, and the accuracy of the communication and the goal set for reaching the operating room improved.

The Decision to Incision Curriculum: Teaching Preoperative Skills and Achieving Level 1 Milestones

OBJECTIVE

To evaluate the effectiveness of a preoperative skills curriculum, and to assess and document competence in associated Obstetrics and Gynecology Level 1 Milestones.

DESIGN

The Decision to Incision curriculum was developed by a team of medical educators with the goal of teaching and evaluating 5 skills pertinent to Milestone 1: Preoperative consent, patient positioning, Foley catheter placement, surgical scrub, and preoperative time-out. Competence, overall skill performance, and knowledge were assessed by evaluator rating using checklists before and after the educational intervention. Differences between preintervention and postintervention skills performance and competence were assessed using Wilcoxon rank test and Fisher exact test, respectively.

SETTING

Clinical Simulation Center at an academic medical center.

PARTICIPANTS

Overall, 29 fourth year medical students matriculating into Obstetrics and Gynecology residencies.

RESULTS

The proportion of participants meeting Milestone competence significantly increased in all 5 skills, with competence achieved in 95.6% (95% CI: 92.1-99.0) of posttest skills assessments. Median overall performance also significantly improved for all 5 skills, with 83.6% (95% CI: 77.3-89.9) earning scores of 4 out of 5 or greater on the posttest. For knowledge testing, the proportion of correct responses significantly increased for both topics evaluated, from 45.2% to 99.7% (p < 0.0001) for positioning and from 32.8% to 83.1% (p < 0.0001) for time-out.

CONCLUSIONS

The decision to incision curriculum significantly improved preoperative skills, including skills that may be required on day 1 of residency. This curriculum also facilitated achievement and documentation of competence in multiple Milestones.

The flipped classroom for medical students

BACKGROUND

The objectives of this curricular innovation project were to implement a flipped classroom curriculum for the gynaecologic oncology topics of the obstetrics and gynaecology medical student clerkship, and to evaluate student satisfaction with the change.

METHODS

Four short online videos on the topics of endometrial hyperplasia, cervical dysplasia, evaluation of an adnexal mass, and ovarian cancer were created, and students were instructed to view them prior to a class-time active learning session. The Learning Activity Management System (lams) open-source online platform was used to create an active learning class-time activity that consisted of a coached discussion of cases. Student satisfaction with the two aspects of the flipped curriculum was obtained. In addition, lecture assessment for the gynaecologic oncology topics and aggregate student performance on the gynaecological oncology questions of the US National Board of Medical Examiners (NBME) Subject Examination were compared before and after implementation of the curriculum.

RESULTS

Eighty-nine students rotated on the clerkship during the pilot period of analysis. Seventy-one students (80%) viewed the videos prior to the class session, and 84 (94%) attended the session. Student satisfaction was very high for both parts of the curriculum. There was no significant difference in aggregate student performance on the gynaecological oncology questions of the NBME Subject Examination. The flipped classroom curriculum demonstrates a promising platform for using technology to make better use of students' time

DISCUSSION

Our implementation of the flipped classroom curriculum for the gynaecologic oncology topics successfully demonstrates a promising platform for using technology to make better use of our students' time, and for increasing their satisfaction with the necessary didactic learning of the clerkship.

Patient responses to research recruitment and follow-up surveys: findings from a diverse multicultural health care setting in Qatar

BACKGROUND

Health care researchers working in the Arabian Gulf need information on how to optimize recruitment and retention of study participants in extremely culturally diverse settings. Implemented in Doha, Qatar in 2012 with 4 language groups, namely Arabic, English, Hindi, and Urdu, this research documents persons' responses to recruitment, consent, follow-up, and reminder procedures during psychometric testing of the Multicultural Assessment Instrument (MAI), a novel self- or interviewer-administered survey.

METHODS

Bilingual research assistants recruited adults in outpatient clinics by approaching persons in particular who appeared to be from a target language group. Participants completed the MAI, a second acculturation instrument used for content-validity assessment, and a demographics questionnaire. Participants were asked to take the MAI again in 2-3 weeks, in person or by post, to assess test-retest reliability. Recruitment data were analyzed by using nonparametric statistics.

RESULTS

Of 1503 persons approached during recruitment, 400 enrolled (27%)-100 per language group. The enrollment rates in the language groups were: Arabic-32%; English-33%; Hindi-18%; Urdu-30%. The groups varied somewhat in their preferences regarding consent procedure, follow-up survey administration, contact mode for follow-up reminders, and disclosure of personal mailing address (for postal follow-up). Over all, telephone was the preferred medium for follow-up reminders. Of 64 persons who accepted a research assistant's invitation for in-person follow-up, 40 participants completed the interview (follow-up rate, 63%); among 126 persons in the postal group with a deliverable address, 29 participants mailed back a completed follow-up survey (response rate, 23%).

CONCLUSIONS

Researchers in the Arabian Gulf face challenges to successfully identify, enroll, and retain eligible study participants. Although bilingual assistants-often from the persons' own culture-recruited face-to-face, and our questionnaire contained no health care-related content, many persons were reluctant to participate. This occurrence was observed especially at follow-up, particularly among participants who had agreed to follow-up by post.

Image-guided intensity-modulated radiotherapy of prostate cancer: Analysis of interfractional errors and acute toxicity

Purpose

The aim of the study was to estimate interfractional deviations in patient and prostate position, the impact of the frequency of online verification on the treatment margins, and to assess acute radiation reactions of high-dose external beam image-guided intensity-modulated radiotherapy (IG-IMRT) of localized prostate cancer.

Patients and methods

IG-IMRT was performed by daily online verification of implanted fiducial prostate markers using a megavoltage electronic portal imaging device (EPID). A total of 1011 image-guided treatment fractions from 23 consecutive unselected prostate cancer patients were analyzed. The median total dose was 79.2 Gy (range 77.4–81.0 Gy). Acute radiation reactions were assessed weekly during radiotherapy using the Common Terminology Criteria for Adverse Events (CTCAE) v.4.03.

Results

A relevant combined patient set-up and prostate motion population random error of 4–5 mm was observed. Compared to daily IGRT, image guidance every other day required an expansion of the CTV–PTV (clinical target volume–planning target volume) margin of 8.1, 6.6, and 4.1 mm in the longitudinal, vertical, and lateral directions, thereby, increasing the PTV by approximately 30–40 %. No grade 3 or 4 acute radiation reactions were observed with daily IG-IMRT.

Conclusion

A high dose with surprisingly low acute toxicity can be applied with daily IG-IMRT using implanted fiducial prostate markers. Daily image guidance is clearly superior to image guidance every other fraction concerning adequate target coverage with minimal margins.

[Role of deep sedation phacoemulsification with scleral tunnel]

PURPOSE

To describe a method of deep sedation without adjunctive periocular injection in phacoemulsification with a scleral tunnel technique.

METHODS

All patients undergoing phacoemulsification with a scleral tunnel and foldable intraocular lens for cataract between May 2011 and November 2014 received deep sedation including a bolus of midazolam and fentanyl followed by a continuous perfusion of dexmedetomidine throughout the surgical procedure. The patients and medical team evaluated pain, sedation, clinical status of the patient, and surgeon comfort.

RESULTS

One thousand and five hundred patients were included, representing 1763 eyes. Ramsay's sedation score was 2 in 7.13% of cases and 3 in 86.3%, which allowed surgery to be performed under very satisfactory conditions. On a scale of 1 to 10, intraoperative pain was less than or equal to 1 in 81.2% of cases. The bradycardic and hypotensive effects of dexmedetomidine were appreciable, while respiratory depression was not observed. Only 1 case of severe agitation during surgery directly resulted in a vitreous issue. Some simple precautions allow optimization of the advantages of this method of anesthesia.

CONCLUSION

The deep sedation method including bolus injections of midazolam and fentanyl and continuous perfusion of dexmedetomidine affords a certain comfort to the patient as well as the surgeon in phacoemulsification of cataract through a scleral tunnel without adjunctive periocular injection.

Safety of a thickened extensive casein hydrolysate formula

OBJECTIVES

Cow's milk allergy (CMA) is treated in formula-fed infants with an extensive protein hydrolysate. This study aimed to evaluate the nutritional safety of a non-thickened and thickened extensively casein hydrolyzed protein formula (NT- and T-eCHF) in infants with CMA.

METHODS

Infants younger than 6 mo old with a positive cow milk challenge test, positive IgE, or skin prick test for cow milk were selected. Weight and length were followed during the 6 mo intervention with the NT-eCHF and T-eCHF.

RESULTS

A challenge was performed in 50/71 infants with suspected CMA and was positive in 34/50. All children with confirmed CMA tolerated the eCHF. The T-eCHF leads to a significant improvement of the stool consistency in the whole population and in the subpopulation of infants with proven CMA. Height and weight evolution was satisfactory throughout the 6 mo study.

CONCLUSIONS

The eCHF fulfills the criteria of a hypoallergenic formula and the NT- and T-eCHF reduced CMA symptoms. Growth was within normal range.

Procedures of recruiting, obtaining informed consent, and compensating research participants in Qatar: findings from a qualitative investigation

BACKGROUND

Very few researchers have reported on procedures of recruiting, obtaining informed consent, and compensating participants in health research in the Arabian Gulf Region. Empirical research can inform the debate about whether to adjust these procedures for culturally diverse settings. Our objective was to delineate procedures related to recruiting, obtaining informed consent, and compensating health research participants in the extremely high-density multicultural setting of Qatar.

METHODS

During a multistage mixed methods project, field observations and qualitative interviews were conducted in a general medicine clinic of a major medical center in Qatar. Participants were chosen based on gender, age, literacy, and preferred language, i.e., Arabic, English, Hindi and Urdu. Qualitative analysis identified themes about recruitment, informed consent, compensation, and other research procedures.

RESULTS

A total of 153 individuals were approached and 84 enrolled; the latter showed a diverse age range (18 to 75 years); varied language representation: Arabic (n = 24), English (n = 20), Hindi (n = 20), and Urdu (n = 20); and balanced gender distribution: women (n = 43) and men (n = 41). Primary reasons for 30 declinations included concern about interview length and recording. The study achieved a 74% participation rate. Qualitative analytics revealed key themes about hesitation to participate, decisions about participation with family members as well as discussions with them as "incidental research participants", the informed consent process, privacy and gender rules of the interview environment, reactions to member checking and compensation, and motivation for participating. Vulnerability emerged as a recurring issue throughout the process among a minority of participants.

CONCLUSIONS

This study from Qatar is the first to provide empirical data on recruitment, informed consent, compensation and other research procedures in a general adult population in the Middle East and Arabian Gulf. This investigation illustrates how potential research participants perceive research participation. Fundamentally, Western ethical research principles were applicable, but required flexibility and culturally informed adaptations.

Preparing medical students for obstetrics and gynecology milestone level one: a description of a pilot curriculum

BACKGROUND

The implementation of the Accreditation Council for Graduate Medical Education (ACGME) Milestones in the field of obstetrics and gynecology has arrived with Milestones Level One defined as the level expected of an incoming first-year resident.

PURPOSE

We designed, implemented, and evaluated a 4-week elective for fourth-year medical school students, which utilized a multimodal approach to teaching and assessing the Milestones Level One competencies.

METHODS

The 78-hour curriculum utilized traditional didactic lectures, flipped classroom active learning sessions, a simulated paging curriculum, simulation training, embalmed cadaver anatomical dissections, and fresh-frozen cadaver operative procedures. We performed an assessment of student knowledge and surgical skills before and after completion of the course. Students also received feedback on their assessment and management of eight simulated paging scenarios. Students completed course content satisfaction surveys at the completion of each of the 4 weeks.

RESULTS

Students demonstrated improvement in knowledge and surgical skills at the completion of the course. Paging confidence trended toward improvement at the completion of the course. Student satisfaction was high for all of the course content, and the active learning components of the curriculum (flipped classroom, simulation, and anatomy sessions) had higher scores than the traditional didactics in all six categories of our student satisfaction survey.

CONCLUSIONS

This pilot study demonstrates a practical approach for preparing fourth-year medical students for the expectations of Milestones Level One in obstetrics and gynecology. This curriculum can serve as a framework as medical schools and specific specialties work to meet the first steps of the ACGME's Next Accreditation System.

Comparison of oral recombinant erythropoietin and subcutaneous recombinant erythropoietin in prevention of anemia of prematurity

BACKGROUND

Premature neonates are at risk for severe anemia and erythropoietin is the most important hormone in erythropoiesis. The aim of this study was to evaluate the influence of oral recombinant human erythropoietin (rhEPO) in proving erythropoiesis in neonates.

METHODS

This was a randomized clinical trial study. Thirty neonates were enrolled from September 2007 to September 2008. The first group received oral rhEPO and Fe and the second, subcutaneous rhEPO and Fe. The patients' Hb, HCT and the need to blood transfusion were recorded. We included all infants with gestational age <34 weeks, birth weight <1500 gr, without respiratory distress (O2 Saturation> 85%, FiO2 of 30%), full feeding tolerance so that oral Fe can be administrated.

RESULTS

In first group (oral=PO), 65% of neonates were female and 35% were male, mean weight was 1140 g and mean GA was 32.6 weeks. In the second group (subcutaneous=SC), 42% were female and 58% were male. The mean weight was 1245 g and mean GA was 31.2 weeks and this was not statistically significant. In the first group, the mean Hb and HCT were 9.7±1.9 and 29.6±5.9 g/dl. In the second group, the figures were 12.5±1.7 and 38.8±5.1 which were statistically significant. There was no difference in the weight gain between two groups. In the first group, 3 neonates (20%) and in the second one, 1 neonate (15%) needed blood transfusion.

CONCLUSIONS

rhEPO administration either PO or SC could prevent anemia of prematurity but SC rout was more effective.

Core clerkship directors: their current resources and the rewards of the role

PURPOSE

To conduct a national multidisciplinary investigation assessing core clinical clerkships and their directors, variances in resources from national guidelines, and the impact of the clerkship director role on faculty members' academic productivity, advancement, and satisfaction.

METHOD

A multidisciplinary working group of the Alliance for Clinical Education (ACE), representing all seven core clinical disciplines, created and distributed a survey to clerkship directors at 125 U.S. MD-granting medical schools, in academic year 2006-2007.

RESULTS

A total of 544 clerkship directors from Internal Medicine (96), Family Medicine (91), Psychiatry, (91), Pediatrics (79), Surgery (71), Neurology (60), and Obstetrics-Gynecology (56) responded, representing over 60% of U.S. core clinical clerkships. The clerkship directors were similar across disciplines in demographics and academic productivity, though clinical and clerkship activities varied. Departmental staff support for clerkships averaged 0.69 people, distinctly less than the ACE's 2003 guideline of a full-time coordinator in all disciplines' clerkships. Clerkship directors reported heavy clinical responsibilities, which, as in previous studies, were negatively related to academic productivity. However, many clerkship directors felt the role enhanced their academic advancement; a large majority felt it significantly enhanced their career satisfaction.

CONCLUSIONS

The resources and rewards of the clerkship director role were similar across disciplines. Expectations of clerkship directors were considerable, including responsibility for clinical material and the learning environment. Resources for many fall short of those stated in the ACE guidelines, particularly regarding support staff. However, the findings indicate that the clerkship director role can have benefits for academic advancement and strongly enhances career satisfaction.

Randomized clinical trial comparing two natural surfactant preparations to treat respiratory distress syndrome

OBJECTIVES

Natural surfactant preparations have been shown to reduce the severity and mortality of respiratory distress syndrome (RDS) in preterm infants. The objective of this study was to compare the efficacy of two natural surfactants, namely SF-RI 1 (Alveofact) and barectant (Survanta), on the incidence of chronic lung disease (CLD) and other associated complications of RDS in preterm infants.

METHODS

Preterm infants with RDS requiring artificial ventilation were randomly selected to receive an initial dose of either Alveofact or Survanta. The two treatment groups were tested for variation in gas exchange, ventilatory settings and neonatal complications such as CLD and mortality.

RESULTS

After 5 days the Survanta-treated infants had a lower fraction of inspired oxygen (FiO2) compared with the Alveofact-treated infants. There were no differences in the ventilatory settings. More infants in the Survanta group were extubated at 3 days and fewer required the use of postnatal steroids. Less CLD and duration of oxygenation were experienced by the Survanta-treated group.

CONCLUSIONS

Improved oxygenation and reduced ventilatory requirements were greater with Survanta compared to Alveofact, which in turn was associated with a trend towards a lower incidence of serious pulmonary complications.

Neonatal infections in Asia

OBJECTIVE

To study the epidemiology (including incidence, antibiotic sensitivity and mortality) of neonatal unit infections in countries in Asia.

METHODS

One year prospective study of neonatal infections in eight neonatal units in Asia.

RESULTS

There were 453 episodes of sepsis affecting 394 babies. Mortality from neonatal sepsis was 10.4%, with an incidence of 0.69 deaths/1000 live births. Group B streptococcus was the most common early-onset organism causing 38% of episodes of early-onset (<48 h old) sepsis, with a rate of 0.51 episodes per 1000 live births and a mortality of 22%. Gram-negative bacillary early-onset sepsis occurred at a rate of 0.15 episodes per 1000 live births with a mortality of 12%. There were 406 episodes of late-onset sepsis. The incidence was high at 11.6 per 1000 live births, and mortality was 8.9%. Coagulase-negative staphylococcus caused 34.1% of episodes, whereas Staphylococcus aureus caused only 5.4%. Gram-negative bacilli caused 189 episodes (46.6%). Only 44% of Gram-negative bacilli were sensitive to both gentamicin and a third-generation cephalosporin, whereas 30% were resistant to both antibiotics. Meningitis occurred in 17.2% of episodes of late sepsis, with a mortality of 20%.

CONCLUSIONS

The incidence of late-onset sepsis was higher in Asia than in resource-rich countries, but the organisms isolated and mortality were similar. Over half of all Gram-negative bacilli were antibiotic resistant.

[Sarcomatoid carcinomas of the upper airways]

INTRODUCTION

The sarcomatoid carcinoma of the superior aerodigestive tracts is a rare malignant tumour which presents diagnostic and therapeutic challenges.

MATERIAL AND METHOD

We report 11 cases of spindle cell carcinomas of the upper airways.

RESULTS

Sex-ratio was 10:1 and the mean age was 57.3 years (30 - 75 years). Nine patients were smokers and 4 presented with a history of radiation exposure. Tumoral locations were as follows: larynx: 6, hypopharynx: 1, oropharynx: 1, nasopharynx: 1, oral cavity: 2. Histological diagnosis in 3 cases required the use of immunohistochemical studies. Four patients were first seen at an advanced stage. This left 9 patients and among them 7 received a curative treatment: 5 by surgery alone, 1 by surgery and radiotherapy, 1 by radiotherapy, 1 by chemo-radiotherapy for the nasopharyngeal lesion and 1 by chemotherapy alone. Two patients died from their disease before treatment. With an average delay of 15.4 months, the rates of global survival and disease-free were 5/9 and 4/9 respectively.

CONCLUSION

The sarcomatoid carcinoma of the upper airways is rare, but not unusual. Its diagnosis benefits from progresses in immunohistochemistry, but also from advances in the field of molecular biology. Its treatment and natural evolution remain controversial.

To the point: Medical education review of the RIME method for the evaluation of medical student clinical performance

This article, the sixth in the ongoing To The Point Series produced by the Association of Professors of Gynecology and Obstetrics Undergraduate Medical Education Committee, reviews the Reporter-Interpreter-Manager-Educator (RIME) method for the evaluation of student clinical performance on the obstetrics and gynecology rotation. This article discusses the inherent challenges of descriptive narrative evaluation and the superiority of the RIME method in producing meaningful evaluation of and feedback for students. The use of the method to fulfill Liaison Committee on Medical Education standards and implementation of the method are described.

To the Point: reviews in medical education online computer assisted instruction materials

Computer technology is rapidly changing the way educators can interact with their students. This article reviews the research regarding the integration of online computer-assisted instructional materials into medical education.

To the point: reviews in medical education teaching techniques

Medical educators are faced with the difficult dilemma of decreased time available for teaching as a result of increased demands for clinical time. Yet few physicians have formal training in teaching methods. Educational research is reviewed to assist educators to select the best teaching technique to meet the learning objectives.

[Diff-Quik(R) staining method for detection and identification of monosodium urate and calcium pyrophosphate crystals in synovial fluids]

The aim of this study was to evaluate whether DQ could prove useful to identify monosodium urate (MSU) and calcium pyrophosphate dehydrate (CPPD) crystals on permanent mounted stained slides. To this end, we studied 27 synovial fluid (SF) samples obtained from the knees of patients with the pseudogout (n=21) and acute gouty arthritis (n=6). Wet analysis for crystal detection and identification was performed within one hour of joint aspiration. In addition, we studied 16 inflammatory synovial effusions obtained from patients with knee arthritis not induced by crystals. For each SF, DQ stained slides were analyzed by 2 experienced doctors in SF analysis. The observers were blinded to the type of crystal present in the SF. Each slide was analyzed by compensated polarized and transmitted light microscopy. SF was considered positive if intracellular and/or extracellular crystals were clearly identified. In addition, the observers were asked to identify the type of the crystals using compensated polarized light microscopy. Sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of the DQ staining method were determined. 51 true positive and 28 true negative specimens were correctly classified (39 CPPD samples, 12 MSU samples, and 28 samples of crystals-unrelated arthropathies). All MSU specimens were correctly diagnosed.

[Full optical correction after cycloplegia in headache]

PURPOSE

To study the advantages of cycloplegia in the accurate assessment of refractive errors and to evaluate the impact of full optical correction in the course of headache.

MATERIAL

and methods: A prospective study was carried out in 164 eyes of 82 patients with headache. Corrected visual acuity was 10/10 in all cases. Refraction was measured before and under cycloplegia by cyclopentolate with a CANON R 50 infrared autorefractometer. Full optical cycloplegic correction based on the value of refraction under cycloplegia was prescribed in all cases. Mean follow-up was 10 months. Statistical analyses were used: Student's t test, Pearson coefficient correlation, and Chi2.

RESULTS

Under cycloplegia, hypermetropia was significantly the most frequent ametropia (67.1%, p<10(- 9)). The difference between the spherical equivalent, before and during cycloplegia, was highly significant (p<10(- 5)) at 0.79. Optical correction eliminated headaches in 76.5% of the cases.

CONCLUSION

The authors conclude on the role of accommodation in headache onset and the need to continue cycloplegia until the age of 45. The importance of optical correction in alleviating headaches is underlined.

Failure of ultrasonic vibration as a means of antigen retrieval in routine diagnostic immunocytochemistry

It was recently reported that certain antigens can be retrieved from paraffin sections of formalin-fixed tissues by ultrasonication using either an expensive and sophisticated ultrasonic cell disrupter probe (cytokeratins 13 and 16) or an inexpensive and generally available ultrasonic cleaning bath (bcl-1). We wished to investigate the routine use of the latter method and therefore tried to retrieve from various tissues 11 antigens that usually require heat-mediated retrieval in citrate buffer. We applied ultrasonic vibration for periods of 30 seconds to 1.5 minutes in a cleaning bath containing citrate buffer or water, with and without the addition of heat, or for 1 minute in hot citrate buffer after microwaving for 10 minutes in the same buffer. Although a slight effect of ultrasound was noted for a few antigens, in no case did the immunostaining reach the level achieved after standard microwave heating in citrate buffer. We conclude that, under the conditions we used, ultrasonic antigen retrieval cannot be used for immunocytochemistry in a routine histopathology laboratory.