The influence of objectives, learning experiences and examination blueprint on medical students' examination preparation.

BACKGROUND: The influence of intended and informal curricula on examination preparation has not been extensively studied. This study aims to firstly describe how students utilized components of intended and informal curricula to guide examination preparation, and secondly to study the relationship between examination preparation and performance. METHODS: Students received a pre-examination questionnaire to identify components from the intended curriculum (objectives and examination blueprint), and informal curriculum (content emphasised during lectures and small groups), used during examination preparation. Multiple logistic regression was used to study the relationship between these variables and student performance (above versus at or below average). RESULTS: Eighty-one students participated. There was no difference in the proportions using the examination blueprint, content emphasised during lectures, and content emphasised during small groups (87-93%) but fewer students used objectives (35%, p < 0.001). Objectives use was associated with reduced odds of above average examination performance (adjusted odds ratio 0.27 [0.07, 0.97], p = 0.04). CONCLUSION: When preparing for the renal course examination, students were influenced at least as much by the informal as the intended curriculum. Of the two intended curriculum components, the examination blueprint appeared to be more widely used than the course objectives. This decreased use of objectives on examination preparation did not appear to have a detrimental effect on student performance.

Diagnostic reasoning strategies and diagnostic success.

PURPOSE: Cognitive psychology research supports the notion that experts use mental frameworks or "schemes", both to organize knowledge in memory and to solve clinical problems. The central purpose of this study was to determine the relationship between problem-solving strategies and the likelihood of diagnostic success. METHODS: Think-aloud protocols were collected to determine the diagnostic reasoning used by experts and non-experts when attempting to diagnose clinical presentations in gastroenterology. RESULTS: Using logistic regression analysis, the study found that there is a relationship between diagnostic reasoning strategy and the likelihood of diagnostic success. Compared to hypothetico-deductive reasoning, the odds of diagnostic success were significantly greater when subjects used the diagnostic strategies of pattern recognition and scheme-inductive reasoning. Two other factors emerged as independent determinants of diagnostic success: expertise and clinical presentation. Not surprisingly, experts outperformed novices, while the content area of the clinical cases in each of the four clinical presentations demonstrated varying degrees of difficulty and thus diagnostic success. CONCLUSIONS: These findings have significant implications for medical educators. It supports the introduction of "schemes" as a means of enhancing memory organization and improving diagnostic success.

Development and evaluation of a Research Project Program for medical students at the University of Calgary Faculty of Medicine.

This essay outlines the development and evaluation of the Research Project Program (RPP) ten years after its introduction into the medical curriculum at the University of Calgary. The RPP consists of two mandatory for-credit courses. Students have the option of conducting either two smaller independent research projects or one larger project over the two years. At the end of the second-year course the students complete an evaluation of the RPP in which they are asked to assess and comment upon various aspects of the program. The authors compared data available from years one (the class of 1990) and ten (the class of 2000) and found significant differences between the two classes' approaches to the RPP. Most of the class of 2000 (89%) carried out two-year independent in-depth research projects spanning a wide range of topics. Half of these projects involved individual collection and analyses of data using experimental methods; this represented a 2.25-fold increase over the first year of the program. In the class of 2000, 44% of students presented their results at a newly implemented research symposium; an additional 22% of students presented their results at local, national, or international meetings. Further, 59% of the class of 2000 had either submitted or were planning to submit their research for peer-reviewed publication. In contrast, none of the students of the class of 1990 formally presented their research, and only 11% planned to submit their research findings for publication. The RPP has evolved in the ten years since its implementation, but the authors believe the program continues to foster independent learning and analytic and problem-solving skills.

A schematic approach to diagnosing and resolving lecturalgia.

BACKGROUND: The lecture is a much used and much criticized teaching method. Lecturalgia (painful lecture) is a frequent cause of morbidity for both teachers and learners. The etiology of lecturalgia is multifactorial and multiple lecturing pathologies frequently coexist. The 'Clinical Presentation' curriculum at the University of Calgary encourages the use of 'schemes' that provide a scaffolding for learning and a starting point for approaching (clinical) problems. Thus far this approach has not been used to tackle teaching or learning problems. AIM: Our aim in this paper was to devise a schematic approach to diagnosing lecturing problems and to make evidence-based recommendations on how to resolve lecturing problems. We have suggested that causes of lecturalgia can be divided into three categories: poor judgement; poor organization; and poor delivery. Our proposed scheme is based upon these three categories that are then subcategorized. RESULTS: We have reviewed the medical education literature in an attempt to provide evidence-based recommendations for the remediation of lecturing problems within each subcategory. CONCLUSION: Where trial evidence is lacking we have made recommendations that are consistent with cognitive theory or expert opinion. Finally, where expert opinion does not exist, we have taken the liberty (literary license) of providing nonexpert opinion!

Conceptual guidelines for developing and maintaining curriculum and examination objectives: the experience of the Medical Council of Canada.

In an era of increasing professional accountability, there is a need for both medical educators and licensing bodies to identify attributes expected of medical graduates. Once these attributes are identified, educators must translate them into meaningful learning objectives. Because educators in many countries are in the process of defining (or have defined) attributes and competencies expected of their graduates, a review of the conceptual basis for writing curricular and examination objectives is relevant and constructive. The authors compare the principles of a conceptual model for identifying educational objectives and those used in the creation of the second (and most current) edition of the Objectives for the Qualifying Examination of the Medical Council of Canada (MCC). In developing these objectives, extensive and careful collaboration between licensing bodies, medical schools, the practicing profession, learners, and the MCC was critical. The process illustrates that the goals for the education of medical students can be consistent whether they are elaborated by medical schools or licensing bodies. The authors present the method and principles used by the MCC, including the clinical presentation model. The basic steps in the process are described: identifying the attributes, identifying the basic educational philosophy, assigning priority to problem-solving principles, and deducing learning objectives from desirable practice-related behaviors. The authors conclude with a consideration of the need and feasibility of defining the scientific underpinnings of competency-based learning objectives.

Long-term knowledge retention following predialysis psychoeducational intervention.

BACKGROUND/AIMS: Early identification and predialysis psychoeducation are gaining acceptance. Although research supports the immediate value of predialysis interventions, long-term benefits remain unknown. We examined long-term knowledge retention following a psychoeducational intervention. METHODS: 47 progressive renal failure patients completed the Kidney Disease Questionnaire at baseline and 18, 30, 42, and 54 months after initiating renal replacement therapy (RRT; the 'longitudinal' sample). A larger cohort provided data at one or more of these points (n = 132, 117, 101, and 70 at 18, 30, 42, and 54 months, respectively; the 'cross-sectional' sample). RESULTS: Initial knowledge gains among psychoeducation recipients were followed by a significant knowledge advantage for three groups throughout follow-up. Patients who received predialysis psychoeducation either before or after starting dialysis demonstrated superior Kidney Disease Questionnaire scores as compared with those identified before the initiation of RRT who received the usual standard of practice. Patients identified after the initiation of RRT and who received standard education, however, demonstrated the same level of knowledge retention as produced by psychoeducation. The results were identical across the longitudinal and cross-sectional samples. CONCLUSIONS: Patient education produces important benefits in end-stage renal disease, but the incremental value of early intervention remains to be demonstrated.

Comparative hospitalization of hemodialysis and peritoneal dialysis patients in Canada.

BACKGROUND: Most comparisons of hemodialysis (HD) and peritoneal dialysis (PD) have used mortality as an outcome. Relatively few studies have directly compared the hospitalization rates, an outcome of perhaps equal importance, of patients using these different dialysis modalities. METHODS: Eight hundred twenty-two consecutive patients at 11 Canadian institutions with irreversible renal failure had an extensive assessment of comorbid illness and initial mode of dialysis collected prospectively immediately prior to starting dialysis therapy. The cohort was assembled between March 1993 and November 1994. The mean follow-up was 24 months. Admission data were used to compare hospitalization rates in HD and PD. RESULTS: Thirty-four percent of patients at baseline and 50% at three months used PD. Twenty-five percent of HD and 32% of PD patients switched dialysis modality at least once after their first treatment (P = NS). Nine percent of HD patients and 30% of PD patients switched modality after three months (P < 0. 001). Total comorbidity was higher in HD patients at baseline (P < 0. 001) and at three months (P = 0.001). The overall hospitalization rate was 40.2 days per 1000 patient days after baseline and 38.0 days per 1000 patient days after three months. When an adjustment was made for baseline comorbid conditions, patients on PD had a lower rate of hospitalization in intention-to-treat analysis according to the type of dialysis in use at baseline (RR 0.85, 95% CI, 0.82 to 0.87, P < 0.001), but a higher rate according to the type of dialysis in use three months after study entry (RR 1.31, 95% CI, 1.27 to 1.34, P < 0.001). In analyses based on the amount of time actually spent on each treatment modality, PD was associated with a higher rate of hospitalization when analyzed according to the type of dialysis in use at baseline (RR 1.10, 95% CI, 1.07 to 1.13, P < 0.001) and according to the type of dialysis in use three months after study entry (RR 1.26, 95% CI, 1.23 to 1.30, P < 0.001). CONCLUSIONS: Conclusions regarding comparative hospitalization rates are heavily dependent on the analytic starting point and on whether intention-to-treat or treatment-received analyses are used. When early treatment switches are accounted for, HD is associated with a lower rate of hospitalization than PD, but the effect is modest.

Use of scheme-based problem solving: an evaluation of the implementation and utilization of schemes in a clinical presentation curriculum.

CONTEXT: The University of Calgary has implemented a new curriculum which is organized according to 120 ways in which patients may present to a physician. Students are taught scheme-based problem solving rather than the more typical hypothetico-deductive or search and scan approach to problem resolution. OBJECTIVE: This study sought to determine the extent to which faculty and students were implementing and utilizing scheme-based problem solving. METHOD: All classes taught within the new clinical presentation curriculum were surveyed at the year end. Participants included four classes of first-year students and three classes of second-year students. Using a 5-point scale, students responded to survey items regarding scheme implementation and utilization. RESULTS: Data were analysed using MANOVA (multivariate analysis of variance) and revealed significant differences among classes in both first- and second-year students. Increments in scheme implementation and utilization by instructors and students were observed, although instructors' utilization of schemes lagged behind that of students. A levelling effect to the benefits of schemes for problem solving was also evident. First-year students reported schemes to be very useful for learning and organizing new information. CONCLUSION: Although it has taken time to implement curriculum change, the student response to schemes has been favourable. Faculty development and further generation of pictorial/spatial representations for all schemes, to ensure that all clinical presentations provide pathways that students can use for both learning and problem solving are recommended. Whether students who utilize schemes are more successful problem solvers is not yet known but will be the subject of study as soon as scheme delivery is predominant.

Comparative mortality of hemodialysis and peritoneal dialysis in Canada.

BACKGROUND: Comparisons of mortality rates in patients on hemodialysis versus those on peritoneal dialysis have been inconsistent. We hypothesized that comorbidity has an important effect on differential survival in these two groups of patients. METHODS: Eight hundred twenty-two consecutive patients at 11 Canadian institutions with irreversible renal failure had an extensive assessment of comorbid illness collected prospectively, immediately prior to starting dialysis therapy. The cohort was assembled between March 1993 and November 1994; vital status was ascertained as of January 1, 1998. RESULTS: The mean follow-up was 24 months. Thirty-four percent of patients at baseline, 50% at three months, and 51% at six months used peritoneal dialysis. Values for a previously validated comorbidity score were higher for patients on hemodialysis at baseline (4.0 vs. 3.1, P < 0.001), three months (3.7 vs. 3.2, P = 0.001), and six months (3.6 vs. 3.2, P = 0.005). The overall mortality was 41%. The unadjusted peritoneal dialysis/hemodialysis mortality hazard ratios were 0.65 (95% CI, 0. 51 to 0.83, P = 0.0005), 0.84 (95% CI, 0.66 to 1.06, P = NS), and 0. 83 (95% CI, 0.64 to 1.08, P = NS) based on the modality of dialysis in use at baseline, three months, and six months, respectively. When adjusted for age, sex, diabetes, cardiac failure, myocardial infarction, peripheral vascular disease, malignancy, and acuity of renal failure, the corresponding hazard ratios were 0.79 (95% CI, 0. 62 to 1.01, P = NS), 1.00 (95% CI, 0.78 to 1.28, P = NS), and 0.95 (95% CI, 0.73 to 1.24, P = NS). Adjustment for a previously validated comorbidity score resulted in hazard ratios of 0.74 (95% CI, 0.58 to 0.94, P = 0.01), 0.94 (95% CI, 0.74 to 1.19, P = NS), and 0.88 (95% CI, 0.68 to 1.13, P = NS) at baseline, three months, and six months. There was no survival advantage for either modality in any of the major subgroups defined by age, sex, or diabetic status. CONCLUSIONS: The apparent survival advantage of peritoneal dialysis in Canada is due to lower comorbidity and a lower burden of acute onset end-stage renal disease at the inception of dialysis therapy. Hemodialysis and peritoneal dialysis, as practiced in Canada in the 1990s, are associated with similar overall survival rates.

Psychosocial impact of illness intrusiveness moderated by self-concept and age in end-stage renal disease.

This study assesses whether a person's self-concept as a "chronic kidney patient" differentially moderates the psychosocial impact of illness intrusiveness--illness-induced lifestyle disruptions--across the life span. Renal transplant (n = 52) and maintenance dialysis patients (n = 49) completed the illness Intrusiveness Ratings Scale, a semantic-differential self-concept measure, and structured interviews measuring psychosocial well-being and emotional distress. Across ages, distress rose with increasing illness intrusiveness when self-concept was similar, but not dissimilar, to the chronic kidney patient stereotype. The relation between illness intrusiveness and psychosocial well-being differed significantly between younger and older respondents depending on whether they construed themselves as similar versus dissimilar to the chronic kidney patient. Although self-definition moderates the psychosocial impact of chronic disease, this varies across the life span and across affect states.

Sorbitol 2.5% mannitol 0.54% irrigation solution for hysteroscopic endometrial ablation surgery.

PURPOSE: To determine if systemic absorption of sorbitol 2.5%/mannitol 0.54% irrigation solution (165 mosm.L-1) during hysteroscopic endometrial ablation with diathermy is associated with hyponatraemia and hypoosmolality. METHODS: In 35 day surgery patients in a university hospital we measured baseline preoperative variables: serum sodium and creatinine concentrations and osmolality, haematocrit, haemoglobin, urine osmolality and sodium concentration, and weight. Fractional excretion of sodium (FENa) was calculated. The same observations were obtained postoperatively before discharge (one hour post resection). Volumes of intraoperative fluid irrigation intravasation and perioperative intravenous fluid absorption (lactated Ringer's solution) were estimated clinically (volumetric). RESULTS: The mean (+/-SD) serum sodium concentration preoperatively was 140.3 +/- 2.4 mmol.L-1; and postoperatively, 139.7 +/- 2.2 mmol.L-1 (P = NS). The serum osmolality decreased from 285.4 +/- 4.5 to 282.6 +/- 4.1 mmol.kg-1 (P < 0.001). The mean volume of intravasated irrigation fluid was 26.4 ml (range 0-300). During the same time, the FENa increased from 0.57% to 0.79% (P < 0.001). CONCLUSION: In these patients, closely and continuously observed for imbalance between infused and collected irrigation fluid, these was no clinical evidence for hyponatraemic hypoosmolality. However, there was a small 1% +/- 1.5% (mean +/- SD; range -3.4 to 3.6%) decrease in plasma osmolality despite adequate blood volumes as shown by urinary sodium indices.

Helping students learn to think like experts when solving clinical problems.

Analysis of problem-solving strategies reveals that although there is no universal, generic problem-solving process, there is a clinical reasoning process that is specific and highly tailored to the complexity of each clinical problem. Research reveals that successful problem solvers must possess comprehensive knowledge, but that the way they organize and understand their knowledge is even more critical. Moreover, using "schemes" for both learning and problem solving provides the advantage of combining the creation of a knowledge structure and a search-and-retrieval strategy into a single operation. (A "scheme" in this context is a mental categorization of knowledge that includes a particular organized way of understanding and responding to a complex situation.) The implication for medical education is that a comprehensive knowledge domain must be appropriately organized for knowledge mastery, which in turn is essential for clinical problem solving. Problem-solving strategies must be specific for each problem and not based on the assumption of a universal generic process. Consequently, a new taxonomy of medical problems is recommended, along with an altered problem-based learning (PBL) format. The "hypothetico-deductive" strategy traditionally used in PBL should be replaced by scheme-driven search strategies so that students develop a more organized and logical approach to problem solving.

Prediction of early death in end-stage renal disease patients starting dialysis.

Demand for dialysis for patients with end-stage renal disease is growing, as is the comorbidity of dialysis patients. Accurate prediction of those destined to die quickly despite dialysis could be useful to patients, providers, and society in making decisions about starting dialysis. To determine whether age and comorbidity accurately predict death within 6 months of first dialysis for end-stage renal disease, a prospective cohort study of 822 patients starting dialysis at one of 11 Canadian centers was performed. Patient characteristics were recorded at first dialysis. Follow-up continued until death or study end (at least 6 months after enrollment). One hundred thirteen of 822 (13.7%) patients died within 6 months. Although an existing scoring system predicted prognosis, adverse scores greater than 9 were found in only 9.7% of those who died; only 52% of those who scored higher than 9 died within 6 months. No score cutoff point combined high true-positive and low false-positive rates for predicting early death. Age, severity of heart failure or peripheral vascular disease, arrhythmias, malnutrition, malignancy, or myeloma were independent prognostic factors identified in multivariate models. However, the best fit discriminant and logistic models were also unable to accurately predict death within 6 months. Clinicians were very accurate in assigning patients to prognostic groups up to a 50% risk of death by 6 months, above which they tended to overestimate risk. However, clinicians were only marginally better than the predictive models in determining whether a given high-risk patient would die. The inability of a scoring system or clinical intuition to accurately predict death soon after starting dialysis for end-stage renal disease suggests that limiting access to dialysis on the basis of likely short survival may be inappropriate in Canada.

The marital context of end-stage renal disease: illness intrusiveness and perceived changes in family environment.

End-stage renal disease (ESRD) is associated with illness-induced disruptions (i.e. illness intrusiveness) that challenge patients and their families to accommodate and adapt. We advance previous research in ESRD by examining the extent to which illness intrusiveness extends to marital, non-marital, and family life among patients and their spouses. We also investigate whether gender and mode of renal replacement therapy moderate these effects. A sample of 19 ESRD patients and their spouses completed the Illness Intrusiveness Ratings Scale and the Family Environment Scale (FES) (completed with reference to two time frames, currently and before ESRD) in structured individual interviews. As hypothesized, ESRD patients reported significantly higher illness intrusiveness than their spouses, but this discrepancy was greater in relation to aspects of non-marital as compared to marital life. Significant moderating effects were observed for gender on the FES Relationship subscale and mode of renal replacement on the FES Personal Growth subscale. Spouses reported significantly more family emphasis on norms and the regulation of family members' behavior (FES System Maintenance) than patients. A pattern of significant correlations linked patient ratings of illness intrusiveness with both premorbid and current family environment. The pattern of findings is consistent with previous clinical reports that women and spouses are more likely than their male and patient counterparts to shoulder much of the burden of adapting family environment to accommodate life with ESRD and renal replacement therapy.

Developing a "clinical presentation" curriculum at the University of Calgary.

Currently, medical curricula are structured according to disciplines, body systems, or clinical problems. Beginning in 1988, the faculty of the University of Calgary Faculty of Medicine (U of C) carefully evaluated the advantages and disadvantages of each of these models in seeking to revise their school's curriculum. However, all three models fell short of a curricular structure based on current knowledge and principles of adult learning, clinical problem solving, community demands, and curriculum management. By 1991, the U of C had formulated a strategic plan for a revised curriculum structure based on the way patients present to physicians, and implementation of this plan has begun. In creating the new curriculum, 120 clinical presentations (e.g., "loss of consciousness/syncope") were defined and each was assigned to an individual or small group of faculty for development based on faculty expertise and interest. Terminal objectives (i.e., "what to do") were defined for each presentation to describe the appropriate clinical behaviors of a graduating physician. Experts developed schemes that outlined how they differentiated one cause (i.e., disease category) from another. The underlying enabling objectives (i.e., knowledge, skills, and attitudes) for reaching the terminal objectives for each clinical presentation were assigned as departmental responsibilities. A new administrative structure evolved in which there is a partnership between a centralized multidisciplinary curriculum committee and the departments. This new competency-based, clinical presentation curriculum is expected to significantly enhance students' development of clinical problem-solving skills and affirms the premise that prudent, continuous updating is essential for improving the quality of medical education.