Measuring the effectiveness of a pilot continuing medical education program.

OBJECTIVE: To evaluate a learner-centred, small group CME program intended to improve the clinical performance of family physicians identified as having serious practice deficiencies by the University of Manitoba's Clinical Assessment and Enhancement Program. DESIGN: Nonrandomized control trial in which data were collected from patients' charts and physician performance was evaluated. Differences in subjects' scores were tested at program entry and at 6 months and 18 months later using a two-way analysis of variance. SETTING: Family medicine practices in Manitoba. PARTICIPANTS: Fifteen family physicians: five study subjects and 10 control subjects. The five study subjects were identified as needing CME to improve their clinical performance. The 10 control subjects were randomly selected. INTERVENTIONS: Participants attended a 10-session, learner-centred, small group CME program. MAIN OUTCOME MEASURES: Clinical care, preventive care, charting, and the use of drugs were the variables assessed. RESULTS: Study subjects' initial scores were much lower than those of controls, but improved significantly during the CME program. CONCLUSION: A learner-centred, small group CME program can improve clinical performance.

Physician-assessment and physician-enhancement programs in Canada.

In the mid-1980s, the licensing authorities in Quebec, Ontario and Manitoba have introduced programs to conduct in-depth assessments of the clinical skills and abilities of physicians with suspected deficiencies. These assessments are intended to supplement the provincial licensing authorities' existing peer review or patient-complaint mechanisms by confirming the physicians' overall level of competence and identifying specific clinical strengths and weaknesses. An "educational prescription", based on the results of the assessment, focuses on aspects of clinical practice in which the physicians need or wish to enhance their skills. In some situations, licensure decisions are based on the assessment information. This article describes the programs in Quebec, Ontario and Manitoba. Each program comprises a different process of personal assessment and individualized continuing medical education to help physicians improve their clinical competence, and each is built on sound principles of clinical competence assessment and educational planning.

Physician-assessment and physician-enhancement programs in Canada.

Since the mid-1980s, the licensing authorities in Quebec, Ontario and Manitoba have introduced programs to conduct in-depth assessments of the clinical skills and abilities of physicians with suspected deficiencies. These assessments are intended to supplement the provincial licensing authorities' existing peer review or patient-complaint mechanisms by confirming the physicians' overall level of competence and identifying specific clinical strengths and weaknesses. An "educational prescription," based on the results of the assessment, focuses on aspects of clinical practice in which the physicians need or wish to enhance their skills. In some situations, licensure decisions are based on the assessment information. This article describes the programs in Quebec, Ontario and Manitoba. Each program comprises a different process of personal assessment and individualized continuing medical education to help physicians improve their clinical competence, and each is built on sound principles of clinical-competence assessment and educational planning.

The accuracy of standardized patient presentation.

The accuracy of standardized patient clinical problem presentation was evaluated by videotape rating of a random sample of 839 student-patient encounters, representing 88 patients, 27 cases and two university test sites. Patient-student encounters were sampled from a collaborative inter-university final-year clinical examination of fourth-year medical students which was conducted at the University of Manitoba and Southern Illinois University in 1987 and 1988. The accuracy, replicability and portability of standardized patient cases were evaluated. The average accuracy of patient presentation was 90.2% in 1987 and 93.4% in 1988. Perfect accuracy scores were obtained by 15 patients; however, 11 patients had average scores below 80% with the accuracy of presentation in some encounters being as low as 30%. There were significant differences in the accuracy score achieved by patients trained together for the same case in 6 of 35 possible comparisons. There was also a systematic trend for patients trained at Southern Illinois to be more accurate in their presentation than patients trained at the University of Manitoba. These differences were significant in 5 of the 15 cases used in the examination.

Evaluating medical performance in the diagnosis and treatment of occupational health problems: a standardized patient approach.

Primary care physicians must identify and manage work-related disease, yet it is unclear whether training is adequate to accomplish this. This study examines the performance of 110 candidates, including 93 4th-year medical students, in the diagnosis and treatment of a standardized patient with occupational illness. Results indicated that the students did substantially better than the medical practitioners who had not received recent training. Although a strong correlation existed between candidates performance on the occupational health (OH) case and overall score on 19 non-occupational health cases, the competency measure that most determined performance on the OH case was interpersonal skills. A correlation also existed between working knowledge, data collection and data interpretation skills overall, and performance on the OH case; diagnostic skills, test selection, test interpretation, and case management skills overall showed no such correlation. The findings highlighted the importance of emphasizing interpersonal skills in training physicians to appropriately manage occupational medical cases, and illustrated the usefulness of standardized patients in teaching and evaluating occupational medical skills.

Myocardial failure and shock in iron poisoning.

Shock is a well-known complication of iron poisoning. Its aetiology is multifactorial with hypovolaemia due to gastrointestinal blood loss and myocardial depression due to systemic acidosis contributing to its genesis. Primary myocardial dysfunction has not been considered to play a role. Our clinical experiences and autopsy findings in three fatal cases of iron poisoning support myocardial dysfunction and damage as contributing factors to their cardiovascular collapse. The three patients, all female, were 3 1/2, 16 and 28-years-old. Onset of shock occurred at 1, 2 and 5 days post-ingestion. There was no response to vigorous fluid replacement therapy and aggressive catecholamine infusions. Central venous pressures were elevated. Microscopic examination of postmortem tissue showed myocardial damage and the presence of stainable iron. It is speculated that the myocardial depression is mediated by lipid peroxidation of myocyte organelle membranes due to iron catalysed free radical generation. The presence of myocardial dysfunction has therapeutic implications. Patients with severe iron poisoning require early and serial measurements of arterial blood pressure, central venous pressure and cardiac output. If primary myocardial dysfunction is documented then fluid replacement, inotropic support and afterload reduction should be considered.

How standardized are standardized patients?

The accuracy and reproducibility of the standardized patient's presentation of a clinical problem was evaluated in 15 cases used in the evaluation of fourth year medical students in two universities. There were differences in the quality of standardized patient presentation between institutions and among the cases presented.

Performance and perception in a simulated clinical encounter.

The feasibility of using data arising from a simulated patient encounter to determine the nature of the relationship between patient satisfaction and examinee performance during a clinical examination is explored. Satisfaction (on dimensions of sensitivity, participation and thoroughness) is shown to be related to aspects of the physical examination and the history taking.