Formative assessments during COVID-19 pandemic: an observational study on performance and experiences of medical students.

Background: Because of COVID-19, the 2020 written medical examinations were replaced by mandatory formative online assessments. This study aimed to determine students' performance, self-assessment of performance, and perception about the switch from a summative to a formative approach. Methods: Medical students from year 2 to 5 (n=648) were included. They could repeat each test once or twice. They rated their performance after each attempt and were then given their score. Detailed feedback was given at the end of the session. An online survey determined medical students' perception about the reorganization of education. Two items concerned the switch from summative to formative assessments Results: Formative assessments involved 2385 examinees totaling 3197 attempts. Among examinees, 30.8% made at least 2 attempts. Scores increased significantly at the second attempt (median 9.4, IQR 10.8), and duration decreased (median -31.0, IQR 48.0). More than half of examinees (54.6%) underestimated their score, female students more often than male. Low performers overestimated, while high performers underestimated their scores. Students approved of the switch to formative assessments. Stress was lessened but motivation for learning decreased. Conclusions: Medical students' better scores at a second attempt support a benefit of detailed feedback, learning time and re-test opportunity on performance. Decreased learning motivation and a minority of students repeating the formative assessments point to the positive influence of summative assessment on learning.

[Palliative sedation in a hospital unit]. / Sédation palliative en unité hospitalière.

A person at the end of life may present uncomfortable symptoms becoming refractory to an adequate treatment. In this case, the initiation of palliative sedation is indicated. Most sedated inpatients die outside a specialized palliative care unit. Palliative sedation must be initiated and adapted according to the best clinical practices. This article describes the processes associated with palliative sedation in a hospital unit.

Une personne en fin de vie peut présenter des symptômes inconfortables devenant réfractaires à un traitement adéquat. Dans ce cas, l'instauration d'une sédation palliative est indiquée. La majorité des patients hospitalisés et sédatés décèdent en dehors d'une unité spécialisée de soins palliatifs. La sédation palliative doit pouvoir être introduite et adaptée selon les règles de bonnes pratiques. Cet article traite des processus liés à la sédation palliative en unité hospitalière.

Recurrent Persistent Hiccups on Opioid Treatment: A Case Report and Literature Review.

Hiccups are a rare but potentially debilitating side effect of opioid treatment, with only a handful of reported cases in the medical literature. The pathophysiological mechanism linking opioids and hiccups is unknown, and a lack of evidence exists concerning the optimal management of the condition. We report on a 64-year-old man diagnosed with advanced renal cancer and painful osteolytic metastases, presenting persistent hiccups while on opioid treatment. Hiccups recurred after multiple challenges with codeine, morphine and hydromorphone on separate occasions. Hiccups ceased only after opioid discontinuation, although various pharmacological treatments were tried to shorten the duration of hiccups. Eventually, fentanyl was introduced and was well tolerated by the patient, without any recurrence of hiccups. The chronological correlation between opioid initiation and the onset of hiccups, as well as opioid discontinuation and the termination of hiccups leads to the conclusion that a causal role of codeine, morphine and hydromorphone in this occurrence is likely. Individual susceptibility probably plays a central role in the development of opioid-related hiccups. Opioid rotation is a promising strategy in the management of opioid-related hiccups, particularly when the mere discontinuation of the opioid is not a viable option, such as in the oncology and palliative care field.

Essential steps in the development, implementation, evaluation and quality assurance of the written part of the Swiss federal licensing examination for human medicine.

Purpose: This report describes the essential steps in the development, implementation, evaluation and quality assurance of the written part of the Swiss Federal Licensing Examination for Human Medicine (FLE) and the insights gained since its introduction in 2011. Methods: Based on existing scientific evidence, international expertise, and experience gained from previous examinations, the FLE is developed by experts from all five medical faculties in Switzerland with the support of the Institute for Medical Education and is held simultaneously at five locations. The exam organisers document and review every examination held and continuously optimise the processes; they have summarised the results in this report. Results: The essential steps comprise the development, revision and translation of questions; construction of the exam and production of materials; candidate preparation; implementation and analysis. The quality assurance measures consist of guideline coherence in the development of the questions and implementation of the exam, revision processes, construction of the exam based on the national blueprint, multiphase review of the translations and exam material, and statistical analysis of the exam and the comments from candidates. The intensive collaboration, especially on the part of representatives from all the participating faculties and a central coordination unit, which provides methodological support throughout and oversees the analysis of the exam, has proven successful. Successfully completed examinations and reliable results in the eleven examinations so far implemented represent the outcomes of the quality assurance measures. Significant insights in recent years are the importance of appreciating the work of those involved and the central organisation of exam development, thus ensuring the long-term success of the process. Conclusion: Common guidelines and workshops, quality assurance measures accompanied by the continuous improvement of all processes, and appreciation of everyone involved, are essential to carrying out such an examination at a high-quality level in the long term.

Palliative care provision for people living with heart failure: The Geneva model.

As life expectancy rises and the survival rate after acute cardiovascular events improves, the number of people living and dying with chronic heart failure is increasing. People suffering from chronic ischemic and non-ischemic heart disease may experience a significant limitation of their quality of life which can be addressed by palliative care. Although international guidelines recommend the implementation of integrated palliative care for patients with heart failure, models of care are scarce and are often limited to patients at the end of life. In this paper, we describe the implementation of a model designed to improve the early integration of palliative care for patients with heart failure. This model has enabled patients to access palliative care when they normally would not have and given them the opportunity to plan their care in line with their values and preferences. However, the effectiveness of this interdisciplinary model of care on patients' quality of life and symptom burden still requires evaluation.

[Serious game, a new approach for advance care planning with dialysis patients]. / « Jeux sérieux ¼, une nouvelle approche pour aborder le projet de soins anticipé avec les patients dialysés.

Due to the high morbidity and mortality with limited life expectancy of dialysis patients, it is essential to implement advance care planning in order to know patients' values and care preferences and respect their autonomy. However, advance care planning is rarely carried out, due to the difficulties in initiating end-of-life discussions, both by patients and healthcare professionals. The use of "serious games" in the form of card games has shown promise in supporting the implementation of advance care planning. In this article, we present the development process of an advance care planning intervention for dialysis patients using a card game (the Go Wish), in the Division of Nephrology of the University Hospitals of Geneva.

[Opiod prescription in primary care: the case of chronic non cancer pain]. / Prescription des opiacés en médecine de premier recours : le cas des douleurs chroniques non cancéreuses.

Pain, including chronic non-cancer pain (CNCP), is a common reason for primary care consultation. CNCP encompasses a heterogeneous group of patients, whose care is often complex. The increase in opioid prescription in Switzerland and worldwide is associated with CNCP, while opioid use for this indication is debated. Several studies suggest a limited effect on pain and function, while adverse effects are frequent. This article aims to summarize what is known about opioid prescription for CNCP and international guidelines and highlight important aspects for the general practitioner.

La douleur, dont la douleur chronique non cancéreuse (DCNC), est un motif de consultation très fréquent en médecine de premier recours. La DCNC regroupe des populations hétérogènes de patients dont la prise en charge est généralement complexe. L'augmentation de la prescription d'opiacés en Suisse et dans le monde concerne davantage les DCNC, alors que l'utilisation d'opiacés pour cette indication est controversée. Différentes études suggèrent que les effets bénéfiques sur la douleur et la fonctionnalité seraient limités contrairement aux effets secondaires relativement fréquents. Cet article a pour but de résumer l'état des connaissances sur la prescription d'opiacés pour les DCNC et les recommandations internationales pour fournir une aide pratique en médecine générale.

[Improving access to palliative care for patients with heart failure: advances and challenges]. / Améliorer l'accès aux soins palliatifs pour les patients atteints d'insuffisance cardiaque chronique - Avancées et défis.

Following the therapeutic progress of the last decades, patients suffering from chronic heart failure (HF) are living longer than ever before. However, recovery from a HF syndrome remains rare and patients more often have to live with chronic HF which considerably impacts their quality of life. For several years, national and international cardiology societies have recommended the early integration of palliative care for HF patients. Although the impact of palliative care on the quality of life, depression and general symptom management of patients with HF has now been clearly established, its implementation is still scarce. The objective of this review is to highlight recommendations and models of care for the implementation of palliative care for patients with HF.

Grâce aux progrès thérapeutiques des dernières décennies, les personnes atteintes d'insuffisance cardiaque (IC) ont une espérance de vie qui augmente. Cependant, la guérison du syndrome d'IC reste rare et le plus souvent les patients vivent avec une IC chronique ayant un impact considérable sur leur qualité de vie. Depuis de nombreuses années, les recommandations nationales et internationales de cardiologie préconisent une prise en charge palliative intégrée et précoce de ces patients. Bien que son impact sur la qualité de vie, la dépression et la gestion globale des symptômes des patients souffrant d'IC soit maintenant clairement démontré, son implémentation dans la pratique reste insuffisante. L'objectif de cet article est de mettre en lumière les recommandations et modèles de prise en charge palliative pour les patients souffrant d'IC.

[COVID-19 pandemics and medical training : supporting and trusting students]. / Pandémie Covid-19 et études médicales : soutenir les étudiant·e·s et leur faire confiance.

The COVID-19 pandemics has deeply impacted academic teaching and forced a complete shift to distance learning formats during the first and second waves. Medical education, among other professional training programs, relies also on practical and clinical immersion, while some of these clinical activities had to be postponed. This article analyzes how one medical school was able to maintain its teaching while ensuring clinical training and taking into account the psychological impact imputed to the lockdown. It also highlights the learning opportunities and unprecedented life experiences contributing to the training of tomorrow's physicians.

La pandémie Covid-19 a imposé à l'enseignement, notamment universitaire, le passage complet à des formats à distance durant les première et deuxième vagues. La formation médicale, entre autres, se caractérise par une forte composante pratique et une immersion clinique. Cet article analyse comment une faculté de médecine a pu maintenir son enseignement en assurant au mieux une formation clinique, en tenant compte autant que possible des conséquences psychologiques objectivées par des enquêtes facultaires. Il valorise également les opportunités d'apprentissage et les expériences inédites amenées par la pandémie et leur intégration dans la formation des médecins de demain.

Medical students' perceptions and coping strategies during the first wave of the COVID-19 pandemic: studies, clinical implication, and professional identity.

BACKGROUND: The unfolding of the COVID-19 pandemic during spring 2020 has disrupted medical education worldwide. The University of Geneva decided to shift on-site classwork to online learning; many exams were transformed from summative to formative evaluations and most clinical activities were suspended. We aimed to investigate the perceived impact of those adaptations by the students at the Faculty of Medicine. METHODS: We sent an online self-administered survey to medical students from years 2 to 6 of the University of Geneva, three months after the beginning of the pandemic. The survey explored students' main activities during the first three months of the pandemic, the impact of the crisis on their personal life, on their training and on their professional identity, the level of stress they experienced and which coping strategies they developed. The survey consisted of open-ended and closed questions and was administered in French. RESULTS: A total of 58.8% of students responded (n = 467) and were homogeneously distributed across gender. At the time of the survey, two thirds of the participants were involved in COVID-19-related activities; 72.5% voluntarily participated, mainly fueled by a desire to help and feel useful. Many participants (58.8%) reported a feeling of isolation encountered since the start of the pandemic. Main coping strategies reported were physical activity and increased telecommunications with their loved ones. Most students described a negative impact of the imposed restrictions on their training, reporting decreased motivation and concentration in an unusual or distraction-prone study environment at home and missing interactions with peers and teachers. Students recruited to help at the hospital in the context of increasing staff needs reported a positive impact due to the enriched clinical exposure. Perceived stress levels were manageable across the surveyed population. If changed, the crisis had a largely positive impact on students' professional identity; most highlighted the importance of the health care profession for society and confirmed their career choice. CONCLUSION: Through this comprehensive picture, our study describes the perceived impact of the pandemic on University of Geneva medical students, their training and their professional identity three months after the start of the pandemic. These results allowed us to gain valuable insight that reinforced the relevance of assessing the evolution of the situation in the long run and the importance of developing institutional support tools for medical students throughout their studies.

Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study.

BACKGROUND: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. OBJECTIVES: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. METHOD: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. RESULTS: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient's comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from -0.05 to 0.42 for patients with advanced disease, and from -0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. CONCLUSION: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.

Physicians' perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study.

OBJECTIVE: The use of intensive care at the end of life can be high, leading to inappropriate healthcare utilisation, and prolonged suffering for patients and families. The objective of the study was to determine which factors influence physicians' admission decisions in situations of potentially non-beneficial intensive care. DESIGN: This is a secondary analysis of a qualitative study exploring the triage process. In-depth interviews were analysed using an inductive approach to thematic content analysis. SETTING: Data were collected in a Swiss tertiary care centre between March and June 2013. PARTICIPANTS: 12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions. RESULTS: Physicians struggled to understand the request for intensive care for patients with advanced disease and full code status. Physicians considered patients' long-term vital and functional prognosis, but they also resorted to shortcuts, that is, a priori consensus about reasons for admitting a patient. Family pressure and unexpected critical events were determinants of admission to the ICU. Patient preferences, ICU physician's expertise and collaborative decision making facilitated refusal. Physicians were willing to admit a patient with advanced disease for a limited amount of time to fulfil a personal need. CONCLUSIONS: In situations of potentially non-beneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Institutional guidelines and timely goals of care discussions with patients with advanced disease and their families could contribute to ensuring appropriate levels of care.

Early advance care planning in amyotrophic lateral sclerosis patients: results of a systematic intervention by a palliative care team in a multidisciplinary management programme - a 4-year cohort study.

INTRODUCTION: Although recommended, the implementation of early advance care planning is suboptimal in amyotrophic lateral sclerosis (ALS) patients. Barriers to advance care planning include healthcare professionals’ and patients’ reluctance, and uncertainty about the right time to initiate a discussion. AIM OF THE STUDY: To determine how often advance care planning was initiated, and the content of the discussion in a first routine palliative care consultation integrated within a multidisciplinary management programme. METHODS: Between June 2012 and September 2016, a prospective cohort study was conducted in Geneva University Hospitals. Sixty-eight patients were seen every 3 months for a 1-day clinical evaluation in a day care centre. RESULTS: The patients’ mean ± standard deviation age was 68.6 ± 11.9 years, 50% were women. Four patients were excluded because of dementia. Advance care planning was initiated with 49 (77%) patients in the first palliative care consultation. Interventions most often addressed were cardiopulmonary resuscitation (49%), intubation and tracheostomy (47%) and palliative sedation (36.7%). Assisted suicide was discussed with 16 patients (36.6%). Functional disability was the only factor associated with initiation of advance care planning. Nearly half of the patients wrote advance directives (45%) or designated a healthcare surrogate (41%). Bulbar onset, functional disability and noninvasive ventilation were not associated with the completion of advance directives. CONCLUSION: Early initiation of advance care planning is feasible in most ALS patients during a routine consultation, and relevant treatment issues can be discussed. All ALS patients should be offered the opportunity to write advance directives as completion was not associated with disease severity. .

Physicians' predictions of long-term survival and functional outcomes do not influence the decision to admit patients with advanced disease to intensive care: A prospective study.

BACKGROUND: Long-term survival and functional outcomes should influence admission decisions to intensive care, especially for patients with advanced disease. AIM: To determine whether physicians' predictions of long-term prognosis influenced admission decisions for patients with and without advanced disease. DESIGN: A prospective study was conducted. Physicians estimated patient survival with intensive care and with care on the ward, and the probability of 4 long-term outcomes: leaving hospital alive, survival at 6 months, recovery of functional status, and recovery of cognitive status. Patient mortality at 28 days was recorded. We built multivariate logistic regression models using admission to the intensive care unit (ICU) as the dependent variable. SETTING/PARTICIPANTS: ICU consultations for medical inpatients at a Swiss tertiary care hospital were included. RESULTS: Of 201 evaluated patients, 105 (52.2%) had an advanced disease and 140 (69.7%) were admitted to the ICU. The probability of admission was strongly associated with the expected short-term survival benefit for patients with or without advanced disease. In contrast, the predicted likelihood that the patient would leave the hospital alive, would be alive 6 months later, would recover functional status, and would recover initial cognitive capacity was not associated with the decision to admit a patient to the ICU. Even for patients with advanced disease, none of these estimated outcomes influenced the admission decision. CONCLUSIONS: ICU admissions of patients with advanced disease were determined by short-term survival benefit, and not by long-term prognosis. Advance care planning and developing decision-aid tools for triage could help limit potentially inappropriate admissions to intensive care.

Multidisciplinary care in amyotrophic lateral sclerosis: a 4-year longitudinal observational study.

Over a four-year period, ALS patients complied with the modalities of the multidisciplinary management follow-up without any drop-outs. The multidisciplinary management structure also contributes to increasing the experience and knowledge of the clinicians involved in managing patients suffering from this rare disease.

Comparison of long-menu and single-best-answer multiple choice questions in computer-based summative assessments: a randomised controlled trial.

BACKGROUND: Little is known regarding the psychometric properties of computerized long-menu formats in comparison to classic formats. We compared single-best-answer (Type A) and long-menu formats using identical question stems during the computer-based, summative, intermediate clinical-clerkship exams for nine disciplines. METHODS: In this randomised sequential trial, we assigned the examinees for every summative exam to either the Type A or long-menu format (four different experimental questions, otherwise identical). The primary outcome was the power of discrimination. The study was carried out at the Faculty of Medicine, University of Geneva, Switzerland, and included all the students enrolled for the exams that were part of the study. Examinees were surveyed about the long-menu format at the end of the trial. RESULTS: The trial was stopped for futility (p = 0.7948) after 22 exams including 88 experimental items. The long-menu format had a similar discriminatory power but was more difficult than the Type A format (71.45% vs 77.80%; p = 0.0001). Over half of the options (54.4%) chosen by the examinees in long-menu formats were not proposed as distractors in the Type A formats. Most examinees agreed that their reasoning strategy was different. CONCLUSIONS: In a non-selected population of examinees taking summative exams, long-menu questions have the same discriminatory power as classic Type A questions, but they are slightly more difficult. They are perceived to be closer to real practice, which could have a positive educational impact. We would recommend their use in the final years of the curriculum, within realistic key-feature problems, to assess clinical reasoning and patient management skills.

Admission to intensive care: A qualitative study of triage and its determinants.

OBJECTIVE: To examine physicians' decision making and its determinants about admission to intensive care. DATA SOURCES/STUDY SETTING: ICU physicians (n = 12) and internists (n = 12) working in a Swiss tertiary care hospital. STUDY DESIGN: We conducted in-depth interviews. DATA COLLECTION/EXTRACTION METHODS: Interviews were analyzed using an inductive thematic approach. PRINCIPAL FINDINGS: Admission decisions regarding seriously ill or elderly patients with comorbidities are complex. Nonmedical factors such as ICU beds availability, health care resources on the ward, information about patient preferences, and family behavior determine the decision. Code status and the quality of interaction between physicians are key determinants. The absence of code status or poor documentation of code status discussions makes decisions more difficult and laden emotionally, as physicians feel they are making a life-death decision. Mutual respect and collaborative decision making facilitate the decision. Tensions arise due to ICU physicians' postponing the decision because of lack of beds, ICU physicians' dismissive attitudes, perceived shortcomings in the other physician's completion of expected tasks, and preconceptions about the other physician. CONCLUSIONS: Systematic documentation of code status, and fostering collaboration between ICU physicians and internists would facilitate ICU admission decisions in complex clinical situations.