The multiple mini-interview for selecting medical residents: first experience in the Middle East region.

INTRODUCTION: Numerous studies have shown that multiple mini-interviews (MMI) provides a standard, fair, and more reliable method for assessing applicants. This article presents the first MMI experience for selection of medical residents in the Middle East culture and an Arab country. METHODS: In 2012, we started using the MMI in interviewing applicants to the residency program of Dubai Health Authority. This interview process consisted of eight, eight-minute structured interview scenarios. Applicants rotated through the stations, each with its own interviewer and scenario. They read the scenario and were requested to discuss the issues with the interviewers. Sociodemographic and station assessment data provided for each applicant were analyzed to determine whether the MMI was a reliable assessment of the non-clinical attributes in the present setting of an Arab country. RESULTS: One hundred and eighty-seven candidates from 27 different countries were interviewed for Dubai Residency Training Program using MMI. They were graduates of 5 medical universities within United Arab Emirates (UAE) and 60 different universities outside UAE. With this applicant's pool, a MMI with eight stations, produced absolute and relative reliability of 0.8 and 0.81, respectively. The person × station interaction contributed 63% of the variance components, the person contributed 34% of the variance components, and the station contributed 2% of the variance components. DISCUSSION: The MMI has been used in numerous universities in English speaking countries. The MMI evaluates non-clinical attributes and this study provides further evidence for its reliability but in a different country and culture. The MMI offers a fair and more reliable assessment of applicants to medical residency programs. The present data show that this assessment technique applied in a non-western country and Arab culture still produced reliable results.

Association between a medical school admission process using the multiple mini-interview and national licensing examination scores.

CONTEXT: There has been difficulty designing medical school admissions processes that provide valid measurement of candidates' nonacademic qualities. OBJECTIVE: To determine whether students deemed acceptable through a revised admissions protocol using a 12-station multiple mini-interview (MMI) outperform others on the 2 parts of the Canadian national licensing examinations (Medical Council of Canada Qualifying Examination [MCCQE]). The MMI process requires candidates to rotate through brief sequential interviews with structured tasks and independent assessment within each interview. DESIGN, SETTING, AND PARTICIPANTS: Cohort study comparing potential medical students who were interviewed at McMaster University using an MMI in 2004 or 2005 and accepted (whether or not they matriculated at McMaster) with those who were interviewed and rejected but gained entry elsewhere. The computer-based MCCQE part I (aimed at assessing medical knowledge and clinical decision making) can be taken on graduation from medical school; MCCQE part II (involving simulated patient interactions testing various aspects of practice) is based on the objective structured clinical examination and typically completed 16 months into postgraduate training. Interviews were granted to 1071 candidates, and those who gained entry could feasibly complete both parts of their licensure examination between May 2007 and March 2011. Scores could be matched on the examinations for 751 (part I) and 623 (part II) interviewees. INTERVENTION: Admissions decisions were made by combining z score transformations of scores assigned to autobiographical essays, grade point average, and MMI performance. Academic and nonacademic measures contributed equally to the final ranking. MAIN OUTCOME MEASURES: Scores on MCCQE part I (standardized cut-score, 390 [SD, 100]) and part II (standardized mean, 500 [SD, 100]). RESULTS: Candidates accepted by the admissions process had higher scores than those who were rejected for part I (mean total score, 531 [95% CI, 524-537] vs 515 [95% CI, 507-522]; P = .003) and for part II (mean total score, 563 [95% CI, 556-570] vs 544 [95% CI, 534-554]; P = .007). Among the accepted group, those who matriculated at McMaster did not outperform those who matriculated elsewhere for part I (mean total score, 524 [95% CI, 515-533] vs 546 [95% CI, 535-557]; P = .004) and for part II (mean total score, 557 [95% CI, 548-566] vs 582 [95% CI, 569-594]; P = .003). CONCLUSION: Compared with students who were rejected by an admission process that used MMI assessment, students who were accepted scored higher on Canadian national licensing examinations.

Analytical derivatizations in environmental analysis.

Analytical derivatization is a technique that alters the structure of an analyte and produces a product more suitable for analysis. While this process can be time-consuming and add reagents to the procedure, it can also facilitate the isolation of the analyte(s), enhance analytes' stability, improve separation and sensitivity, and reduce matrix interferences. Since derivatization is a functional group analysis, it improves selectivity by separating reactive from neutral compounds during sample preparation. This technique introduces detector-orientated tags into analytes that lack suitable physicochemical properties for detection at low concentrations. Notably, many regulatory bodies, especially those in the environmental field, require these characteristics in analytical methods. This review focuses on note-worthy analytical derivatization methods employed in environmental analyses with functional groups, phenol, carboxylic acid, aldehyde, ketone, and thiol in aqueous, soil, and atmospheric sample matrices. Both advantages and disadvantages of analytical derivatization techniques are discussed. In addition, we discuss the future directions of analytical derivatization methods in environmental analysis and the potential challenges.

Performance of the microINR Point-of-Care System Used by Self-Testing Patients: A Multicenter Clinical Trial.

Introduction Anticoagulation monitoring is a major practical and clinical challenge. We assessed the performance of the microINR system in patient self-testing (PST). Methods This study was performed at four US medical centers. After the training visit of warfarin anticoagulated patients ( n = 117) on microINR system, PST was performed at home and in two visits to the medical centers. At the medical centers, both PST and healthcare professionals (HCPs) performed duplicate tests with the microINR System. A venous blood sample for the laboratory testing was also extracted. Accuracy and precision were assessed. Results The comparison between microINR PST results and microINR HCP results revealed an equivalence with a slope of 1.00 (95% confidence interval [CI]: 1.00-1.00), and an intercept of 0.00 (95% CI: 0.00-0.00). When compared with the laboratory analyzer, microINR PST results also showed good correlation with a slope of 0.94 (95% CI: 0.86-1.04) and an intercept of 0.14 (95% CI: -0.09-0.34). Predicted bias values at international normalized ratio (INR) 2.0, 3.5, and 4.5 were 0% against HCP and ≤2.5% against the laboratory. Analytical agreement with both HCP and laboratory was 100% according to ISO17593 and 99.1 and 100% according to CLSI POCT14 with HCP and laboratory, respectively. Clinical agreement with HCP regarding 2.0-4.0 as INR therapeutic range was 98% (within range). The precision (coefficient of variation) of microINR system used by PST was comparable to HCP. Conclusion The microINR results when used by self-testing patients show satisfactory concordance to both HCP results and laboratory analyzer. The microINR system is adequate for self-testing use.

Predictive validity of the multiple mini-interview for selecting medical trainees.

INTRODUCTION: In this paper we report on further tests of the validity of the multiple mini-interview (MMI) selection process, comparing MMI scores with those achieved on a national high-stakes clinical skills examination. We also continue to explore the stability of candidate performance and the extent to which so-called 'cognitive' and 'non-cognitive' qualities should be deemed independent of one another. METHODS: To examine predictive validity, MMI data were matched with licensing examination data for both undergraduate (n = 34) and postgraduate (n = 22) samples of participants. To assess the stability of candidate performance, reliability coefficients were generated for eight distinct samples. Finally, correlations were calculated between 'cognitive' and 'non-cognitive' measures of ability collected in the admissions procedure, on graduation from medical school and 18 months into postgraduate training. RESULTS: The median reliability of eight administrations of the MMI in various cohorts was 0.73 when 12 10-minute stations were used with one examiner per station. The correlation between performance on the MMI and number of stations passed on an objective structured clinical examination-based licensing examination was r = 0.43 (P < 0.05) in a postgraduate sample and r = 0.35 (P < 0.05) in an undergraduate sample of subjects who sat the MMI 5 years prior to sitting the licensing examination. The correlation between 'cognitive' and 'non-cognitive' assessment instruments increased with time in training (i.e. as the focus of the assessments became more tailored to the clinical practice of medicine). DISCUSSION: Further evidence for the validity of the MMI approach to making admissions decisions has been provided. More generally, the reported findings cast further doubt on the extent to which performance can be captured with trait-based models of ability. Finally, although a complementary predictive relationship has consistently been observed between grade point average and MMI results, the extent to which cognitive and non-cognitive qualities are distinct appears to depend on the scope of practice within which the two classes of qualities are assessed.

Oncogenes and Angiogenesis: down-regulation of thrombospondin-1 in normal fibroblasts exposed to factors from cancer cells harboring mutant ras.

The onset of angiogenesis in cancer often involves down-regulation of endogenous angiogenesis inhibitors, of which thrombospondin-1 (TSP-1) is a paradigm. As this effect is thought to occur under the influence of transforming genetic lesions (e.g., expression of the mutant ras oncogene), its nature is regarded as intrinsic to cancer cells themselves. Here, we show that ras-transformed cancer cells can also induce TSP-1 down-regulation in their adjacent nontransformed stromal fibroblasts, but not in endothelial cells, in a paracrine and distance-dependent manner. Indeed, several H-ras-expressing fibrosarcoma (528ras1, B6ras, and NIH3T3Ras) and carcinoma (DLD-1 and IEC18Ras3) cells were found to release soluble factors capable of suppressing TSP-1 protein, mRNA, and promoter activity in nontumorigenic, immortalized dermal fibroblastic cell lines in culture (e.g., in fibroblasts expressing enhanced green fluorescent protein/TSP-1 reporter). This effect was abrogated in Id1-/- fibroblasts. At least two low molecular weight (<3 kDa), heat-labile, and trypsin-resistant mediators of TSP-1 suppression were found to be released from 528ras1 cells. Their effects on normal fibroblasts were inhibited (albeit to different extents) by pertussis toxin and, in one case, by dimethylsphingosine, none of which affected TSP-1 expression by 528ras1 cells. Collectively, our study suggests that the effect of mutant ras on tumor neovascularization is not limited to changes in angiogenic properties of cancer cells themselves. Rather, mutant ras, through a different signaling mechanism, may modulate the properties of the adjacent normal stroma, thus eliciting a proangiogenic field effect.

The ability of the multiple mini-interview to predict preclerkship performance in medical school.

PROBLEM STATEMENT AND BACKGROUND: One of the greatest challenges continuing to face medical educators is the development of an admissions protocol that provides valid information pertaining to the noncognitive qualities candidates possess. An innovative protocol, the Multiple Mini-Interview, has recently been shown to be feasible, acceptable, and reliable. This article presents a first assessment of the technique's validity. METHOD: Forty five candidates to the Undergraduate MD program at McMaster University participated in an MMI in Spring 2002 and enrolled in the program the following autumn. Performance on this tool and on the traditional protocol was compared to performance on preclerkship evaluation exercises. RESULTS: The MMI was the best predictor of objective structured clinical examination performance and grade point average was the most consistent predictor of performance on multiple-choice question examinations of medical knowledge. CONCLUSIONS: While further validity testing is required, the MMI appears better able to predict preclerkship performance relative to traditional tools designed to assess the noncognitive qualities of applicants.

The relationship between interviewers' characteristics and ratings assigned during a multiple mini-interview.

PURPOSE: To assess the consistency of ratings assigned by health sciences faculty members relative to community members during an innovative admissions protocol called the Multiple Mini-Interview (MMI). METHOD: A nine-station MMI was created and 54 candidates to an undergraduate MD program participated in the exercise in Spring 2003. Three stations were staffed with a pair of faculty members, three with a pair of community members, and three with one member of each group. Raters completed a four-item evaluation form. All participants completed post-MMI questionnaires. Generalizability Theory was used to examine the consistency of the ratings provided within each of these three subgroups. RESULTS: The overall test reliability was found to be .78 and a Decision Study suggested that admissions committees should distribute their resources by increasing the number of interviews to which candidates are exposed rather than increasing the number of interviewers within each interview. Divergence of ratings was greater within the pairing of community member to faculty member and least for pairings of community members. Participants responded positively to the MMI. CONCLUSION: The MMI provides a reliable protocol for assessing the personal qualities of candidates by accounting for context specificity with a multiple sampling approach. Increasing the heterogeneity of interviewers may increase the heterogeneity of the accepted group of candidates. Further work will determine the extent to which different groups of raters provide equally valid (albeit different) judgments.

Solid phase analytical derivatization as a sample preparation method.

Analytical derivatization (AD) is an important procedure in analysis as it improves the sensitivity, selectivity and chromatographic separation. Solid phase analytical derivatization (SPAD) combines extraction and derivatization into a single step fulfilling many aspects of a good sample preparation technique, which includes low organic solvent consumption, economical, ease of automation with any chromatographic system and applicability in a wide range of complicated matrices. In this review we have focused on wide applications of SPAD when used in combination with different sample preparation methods, such as solid phase extraction, ion exchange resins, solid phase microextraction, in-tube, microfluidic devices, and hollow fiber extraction methods.

Solid phase analytical derivatization of anthropogenic and natural phenolic estrogen mimics with pentafluoropyridine for gas chromatography-mass spectrometry.

A simple, low cost, fast and sensitive method is reported for the determination of the four endocrine disrupting chemicals (EDCs) 4-tert-butylphenol, 4-tert-octylphenol, bisphenol A and 17ß-estradiol using pentafluoropyridine as the derivatizing reagent. These EDCs were determined by simultaneous extraction and derivatization in a solid phase analytical derivatization (SPAD) technique without the aid of any phase transfer catalyst (PTC) or an ion-pair mechanism. Recoveries of analytes as their tetrafluoropyridyl derivatives from water ranged from 71% for 4-tert-butylphenol to 106% for 17ß-estradiol; from urine they ranged from 61% for 17ß-estradiol to 91% for 4-tert-octylphenol; and from humic acids solution the ranged from 59% for 17ß-estradiol to 104% for 4-tert-octylphenol in humic acid solutions. Calibration curves were constructed from a matrix of human male urine in the range 1-40 ng/mL and had coefficients of correlation greater than 0.99. For 4-tert-butylphenol, bisphenol A and 17ß-estradiol the limits of quantitation were 5 ng/mL and for 4-tert-octylphenol it was 1 ng/mL. This method was applied to determine EDCs and detected 4-tert-octylphenol, bisphenol A and 17ß-estradiol in concentrations comparable to those found in the literature. The method offers advantages in speed of analysis, reduced reagent and specificity of derivatization.

Determination of malondialdehyde in human plasma by fully automated solid phase analytical derivatization.

Analytical derivatization (AD) increases the sensitivity of analysis by one to three orders of magnitude, stabilizes labile analytes and converts them into readily extractable products. Using a variant of this technique, we applied solid phase analytical derivatization (SPAD) to fully automate extraction, derivatization and liquid chromatography. The resulting device (AutoSPAD) determined malonyldialdehyde (MDA) from biological fluids. This biomarker of oxidative stress is highly water-soluble (500 g/L at pH 7), chemically labile and lacks any functionality that enables detection at high sensitivity. AutoSPAD utilizes column-switching technology to load DANSYL hydrazine onto the solid phase, pass the biological sample over the resulting reactor bed for derivatization on the surface to form a hydrophobic derivative suitable for increasing sensitivity of any other LC technique including LC-MS/MS. The hydrophobic solid phase retains the derivative during washing steps, following which AutoSPAD transfers the derivatized extract to the analytical column for separation and detection by fluorescence. In plasma, however, MDA exists both in free form and covalently bound to protein. Measuring MDA from plasma, therefore, required identification of appropriate protein precipitation and hydrolysis conditions. Under these conditions, the DANSYL derivative formed at only one aldehydic position but did not cyclize as reported for other reactions between hydrazine reagents and MDA. The calibration curve using approximately 7 microL of plasma was linear (r(2)=0.999) in the physiological range (0.1-3 microg/mL) and the relative standard deviation of replicate determinations at 1 microg/mL was less than 5%.

Automated derivatization and analysis of malondialdehyde using column switching sample preparation HPLC with fluorescence detection.

Analyte derivatization is advantageous for the analysis of malondialdehyde (MDA) as a biomarker of oxidative stress in biological samples. Conventionally, however, derivatization is time consuming, error-prone and has limited options for automation. We have addressed these challenges for the solid phase analytical derivatization of MDA from small volume tissue homogenate samples. A manual derivatization method was first developed using Amberlite XAD-2 (12 mg) as the solid phase. Subsequently an automated column switching process was developed that provided simultaneous derivatization and extraction of the MDA-DH hydrazone product on a cartridge packed with XAD-2, followed by quantitative elution of the product to an analytical LC column (Waters NovoPak C18, 3.9 x 150 mm). The LOD was 0.02 microg/mL and recovery was quantitative. The method was linear (r(2) >0.999) with precision < 5% from the LOQ (0.06 microg/mL) to at least 35 microg/mL. The method was successfully applied to the analysis of small volume (30 microL) mouse tissue homogenate samples. Endogenous levels of MDA in the tissues ranged from 20 to 40 nmol/g tissue (ca. 0.1-0.2 microg/mL homogenate). Compared to conventional MDA analyses, the current method has advantages in automation, selectivity, precision and sensitivity for analysis from very small sample volumes.

A cost efficiency comparison between the multiple mini-interview and traditional admissions interviews.

A major expense for most professional training programs, both financially and in terms of human resources, is the interview process used to make admissions decisions. Still, most programs view this as a necessary cost given that the personal interview provides an opportunity to recruit potential candidates, showing them what the program has to offer, and to try and gather more information about the candidates to ensure that those selected live up to the espoused values of the institution. We now have five years worth of experience with a Multiple Mini-Interview (MMI) process that, unlike traditional panel interviews, uses the OSCE model to have candidates interact with a larger number of interviewers. We have found that the MMI is more reliable and has better predictive power than our traditional panel interviews. Still, the extent to which any measurement is valuable depends also on the feasibility of use. In this paper we report on an exploration of the cost effectiveness of the MMI as compared to standard panel-based interviews by considering the generation of interview material, human resource (i.e., interviewer and support staff) use, infrastructure requirements, and other miscellaneous expenses. Our conclusion is that the MMI requires greater preparatory efforts and a larger number of rooms to carry out the interviews relative to panel-based interviews, but that these cost disadvantages are offset by the MMI requiring fewer person-hours of effort. The absolute costs will vary dependent on institution, but the framework presented in this paper will hopefully provide greater guidance regarding logistical requirements and anticipated budget.

Restoration of vitamin C synthesis in transgenic Gulo-/- mice by helper-dependent adenovirus-based expression of gulonolactone oxidase.

Inability to synthesize vitamin C, because of a deficiency in gulonolactone oxidase (GULO) expression, is a genetic deficiency shared by a small number of animals including humans. Although the most overt symptom of vitamin C deficiency, scurvy, can be readily corrected by modest consumption of vitamin C, there is increasing interest in the effect of high-level administration in treating human disease. Using a previously derived Gulo-expressing vector, which produces murine GULO under the control of the murine cytomegalovirus (mCMV) promoter, we constructed and validated a recombinant helper-dependent adenovirus (HDAd-mCMV-Gulo) that can be used to correct this genetic defect. A human liver cell line (Hep G2) infected with the HDAd-mCMV-Gulo vector expressed GULO in a time- and gene dose-dependent manner. These cells also produced ascorbic acid when exogenous gulonolactone was supplemented in the medium. Likewise, Gulo(-/-) mice treated with HDAd-mCMV-Gulo at 2 x 10(11) VP expressed GULO in the liver and produced ascorbic acid. Serum ascorbic acid concentrations in Gulo(-/-) mice injected with GULO-expressing HDAd were elevated to levels comparable to those of wild-type mice (62 +/- 15 microM) after 4 days of infection and were maintained at significantly higher levels compared with those in untreated Gulo(-/-) mice for at least 23 days. A similar elevation was observed in urine and tissue ascorbic acid concentrations in vector-treated animals. In conclusion, we demonstrate here that gene therapeutic HDAd-mCMV-Gulo vectors can mediate the expression of GULO and endogenous production of ascorbic acid in human cells and in Gulo(-/-) transgenic mice. Taken together, these data show that a gene therapy approach can be successfully employed in the treatment and further study of vitamin C deficiency in scurvy-prone mammals.

Multiple mini-interviews predict clerkship and licensing examination performance.

OBJECTIVE: The Multiple Mini-Interview (MMI) has previously been shown to have a positive correlation with early medical school performance. Data have matured to allow comparison with clerkship evaluations and national licensing examinations. METHODS: Of 117 applicants to the Michael G DeGroote School of Medicine at McMaster University who had scores on the MMI, traditional non-cognitive measures, and undergraduate grade point average (uGPA), 45 were admitted and followed through clerkship evaluations and Part I of the Medical Council of Canada Qualifying Examination (MCCQE). Clerkship evaluations consisted of clerkship summary ratings, a clerkship objective structured clinical examination (OSCE), and progress test score (a 180-item, multiple-choice test). The MCCQE includes subsections relevant to medical specialties and relevant to broader legal and ethical issues (Population Health and the Considerations of the Legal, Ethical and Organisational Aspects of Medicine[CLEO/PHELO]). RESULTS: In-programme, MMI was the best predictor of OSCE performance, clerkship encounter cards, and clerkship performance ratings. On the MCCQE Part I, MMI significantly predicted CLEO/PHELO scores and clinical decision-making (CDM) scores. None of these assessments were predicted by other non-cognitive admissions measures or uGPA. Only uGPA predicted progress test scores and the MCQ-based specialty-specific subsections of the MCCQE Part I. DISCUSSION: The MMI complements pre-admission cognitive measures to predict performance outcomes during clerkship and on the Canadian national licensing examination.

The effect of defined violations of test security on admissions outcomes using multiple mini-interviews.

INTRODUCTION: Heterogeneous results exist regarding the impact of security violations on student performances in objective structured clinical examinations (OSCEs). Three separate studies investigate whether anticipated security violations result in undesirable enhancement of MMI performance ratings. METHODS: Study 1: low-stakes: MMI station stems provided to a random half of 57 medical school applicants 2 weeks in advance of participation in a research study. Study 2: high-stakes: 384 medical school applicants sat a 12-station MMI to determine admission. Each half received 1 of 2 pilot MMI station stems 2 weeks in advance. Study 3: high-stakes: 38 interviewees with dual applications to occupational therapy and physiotherapy experienced the same 7-station MMI twice on the same date. RESULTS: No statistically significant differences in MMI performances were detected. CONCLUSIONS: Predictable violations of MMI security do not unduly influence applicant performance ratings.

An admissions OSCE: the multiple mini-interview.

CONTEXT: Although health sciences programmes continue to value non-cognitive variables such as interpersonal skills and professionalism, it is not clear that current admissions tools like the personal interview are capable of assessing ability in these domains. Hypothesising that many of the problems with the personal interview might be explained, at least in part, by it being yet another measurement tool that is plagued by context specificity, we have attempted to develop a multiple sample approach to the personal interview. METHODS: A group of 117 applicants to the undergraduate MD programme at McMaster University participated in a multiple mini-interview (MMI), consisting of 10 short objective structured clinical examination (OSCE)-style stations, in which they were presented with scenarios that required them to discuss a health-related issue (e.g. the use of placebos) with an interviewer, interact with a standardised confederate while an examiner observed the interpersonal skills displayed, or answer traditional interview questions. RESULTS: The reliability of the MMI was observed to be 0.65. Furthermore, the hypothesis that context specificity might reduce the validity of traditional interviews was supported by the finding that the variance component attributable to candidate-station interaction was greater than that attributable to candidate. Both applicants and examiners were positive about the experience and the potential for this protocol. DISCUSSION: The principles used in developing this new admissions instrument, the flexibility inherent in the multiple mini-interview, and its feasibility and cost-effectiveness are discussed.

Do clinical clerks provide candidates with adequate formative assessment during Objective Structured Clinical Examinations?

CONTEXT: Various research studies have examined the question of whether expert or non-expert raters, faculty or students, evaluators or standardized patients, give more reliable and valid summative assessments of performance on Objective Structured Clinical Examinations (OSCEs). Less studied has been the question of whether or not non-faculty raters can provide formative feedback that allows students to take advantage of the educational opportunity that OSCEs provide. This question is becoming increasingly important, however, as the strain on faculty resources increases. METHODS: A questionnaire was developed to assess the quality of feedback that medical examiners provide during OSCEs. It was pilot tested for reliability using video recordings of OSCE performances. The questionnaires were then used to evaluate the feedback given during an actual OSCE in which clinical clerks, residents, and faculty were used as examiners on two randomly selected test stations. RESULTS: The inter-rater reliability of the 19-item feedback questionnaire was 0.69 during the pilot test. The internal consistency was found to be 0.90 during pilot testing and 0.95 in the real OSCE. Using this form, the feedback ratings assigned to clinical clerks were significantly greater than those assigned to faculty evaluators. Furthermore, performance on the same OSCE stations eight months later was not impaired by having been evaluated by student examiners. DISCUSSION: While evidence of mark inflation within the clinical clerk examiners should be addressed with examiner training, the current results suggest that clerks are capable of giving adequate formative feedback to more junior colleagues.