Fibrocartilaginous Tissue: Why Does It Fail to Heal?

Tendons and ligaments are critical components in the function of the musculoskeletal system, as they provide stability and guide motion for the biomechanical transmission of forces into bone. Several common injuries in the foot and ankle require the repair of ruptured or attenuated tendon or ligament to its osseous insertion. Understanding the structure and function of injured ligaments and tendons is complicated by the variability and unpredictable nature of their healing. The healing process at the tendon/ligament to bone interface is challenging and often frustrating to foot and ankle surgeons, as they have a high failure rate necessitating the need for revision.

The electroconvulsive therapy and anesthesia exercise (ECTAE): the creation of an interdisciplinary learning activity for medical students.

OBJECTIVES: Demonstration of the effectiveness for medical student teaching of the electroconvulsive therapy (ECT)-anesthesia exercise (ECTAE). The ECTAE is a self-directed, interdisciplinary (psychiatry and anesthesia) learning exercise. Students are taught the assessment of mood and cognition using structured interviewing methods (psychiatry), basic airway and pharmacologic management (anesthesia), and informed consent and interdisciplinary communication (both). There are online pre-exercise and postexercise assessments. METHODS: Third-year medical students reviewed educational reference materials, participated in ECT clinical encounters with both psychiatry and anesthesia, and debriefed after completion of the interdisciplinary exercise. The impact of the exercise was evaluated through online pre- and postexercise assessments. Quantitative and qualitative results for 3 student cohorts (2007 through 2010) were analyzed. RESULTS: Thirty-eight students participated the study over 3 years. Mean scores for 21 true-false questions increased from 14.3 to 17.5 (n = 30) with P < 0.0001. Similarly, mean scores for 11 multiple choice questions increased from 6.8 to 8.9 (n = 22) with P < 0.0001. Thirty of 31 students who completed the program evaluation reported greater comfort level discussing and recommending ECT after participation in ECTAE. CONCLUSIONS: The ECTAE is an effective learning activity for medical students, which incorporates cross-disciplinary learning objectives through self-directed exercises, online assessments, and actual clinical experience of ECT. It improves student knowledge of both psychiatry and anesthesia learning objectives, as well as increasing comfort about ECT. Further research could determine if this activity is easily transportable to other academic settings.

Faculty verbal evaluations reveal strategies used to promote medical student performance.

BACKGROUND: Preceptors rarely follow medical students' developing clinical performance over time and across disciplines. This study analyzes preceptors' descriptions of longitudinal integrated clerkship (LIC) students' clinical development and their identification of strategies to guide students' progress. METHODS: We used a common evaluation framework, reporter-interpreter-manager-educator, to guide multidisciplinary LIC preceptors' discussions of students' progress. We conducted thematic analysis of transcripts from preceptors' (seven longitudinal ambulatory preceptors per student) quarterly group discussions of 15 students' performance over one year. RESULTS: All students' clinical development progressed, although most experienced obstacles. Lack of structure in the history and physical exam commonly obstructed progression. Preceptors used templates for data gathering, and modeling or experiences in the inpatient setting to provide time and solidify structure. To advance students' knowledge acquisition, many preceptors identified focused learning topics with their students; to promote application of knowledge, preceptors used reasoning strategies to teach the steps involved in synthesizing clinical data. Preceptors shared accountability for helping students advance as the LIC allowed them to follow students' response to teaching strategies. DISCUSSION: These results depict preceptors' perceptions of LIC students' developmental continuum and illustrate how multidisciplinary preceptors can use a common evaluation framework to identify strategies to improve performance and follow students' performance longitudinally.

Perceptions of evaluation in longitudinal versus traditional clerkships.

OBJECTIVES: Methods for evaluating student performance in clerkships traditionally suffer shortcomings, partly as a result of clerkship structure. The purpose of this study was to compare preceptors' and students' perceptions of student evaluation in block clerkships and longitudinal integrated clerkships (LICs). METHODS: From 2007 to 2009, preceptors who taught on both block clerkships and an LIC were surveyed on their perceptions of clerkship evaluation. Year 3 students were surveyed on their perceptions of clerkship evaluation at the year end. Responses from preceptors who completed both block clerkship and LIC surveys were compared using paired-samples t-test; student responses were compared using independent-samples t-test. RESULTS: Overall, 66% (67/102) of block clerkship and 75% (77/102) of LIC preceptors responded; 44% of preceptors (45/102) completed both block and LIC surveys. In total, 62% (68/110) of block clerkship and 83% (19/23) of LIC students responded. Both preceptors and students favoured evaluation in the LIC on three factors (p ≤ 0.01): validity of evaluation process, quality of clinical skill evaluation, and willingness to provide constructive feedback. CONCLUSIONS: Preceptors and students perceived evaluation in an LIC more favourably than evaluation on block clerkships. For educators working to improve student evaluation, further examination of the LIC structure and evaluation processes that seem to enhance both formative assessment and summative evaluation may be useful to improve the quality of evaluation and feedback.

Development of a longitudinal integrated clerkship at an academic medical center.

In 2005, medical educators at the University of California, San Francisco (UCSF), began developing the Parnassus Integrated Student Clinical Experiences (PISCES) program, a year-long longitudinal integrated clerkship at its academic medical center. The principles guiding this new clerkship were continuity with faculty preceptors, patients, and peers; a developmentally progressive curriculum with an emphasis on interdisciplinary teaching; and exposure to undiagnosed illness in acute and chronic care settings. Innovative elements included quarterly student evaluation sessions with all preceptors together, peer-to-peer evaluation, and oversight advising with an assigned faculty member. PISCES launched with eight medical students for the 2007/2008 academic year and expanded to 15 students for 2008/2009. Compared to UCSF's traditional core clerkships, evaluations from PISCES indicated significantly higher student satisfaction with faculty teaching, formal didactics, direct observation of clinical skills, and feedback. Student performance on discipline-specific examinations and United States Medical Licensing Examination step 2 CK was equivalent to and on standardized patient examinations was slightly superior to that of traditional peers. Participants' career interests ranged from primary care to surgical subspecialties. These results demonstrate that a longitudinal integrated clerkship can be implemented successfully at a tertiary care academic medical center.

Development and initial testing of a structured clinical observation tool to assess pharmacotherapy competence.

OBJECTIVE: the authors developed and tested the feasibility and utility of a new direct-observation instrument to assess trainee performance of a medication management session. METHODS: the Psychopharmacotherapy-Structured Clinical Observation (P-SCO) instrument was developed based on multiple sources of expertise and then implemented in 4 university-based outpatient medication management clinics with 7 faculty supervising 17 third-year residents. After each observation by a faculty member of a medication management session, residents received feedback in writing (the completed P-SCO) and verbally in person. Targets were 8 P-SCO observations per academic year per resident (or 0.67 per month) and 16 observations per year completed by each faculty (or 1.3 per month). Qualitative thematic analysis was employed to compare the frequency, specificity, type (reinforcing vs. corrective), and content of comments documented on the P-SCO forms to mid-point and end of rotation global assessments by the same faculty for the same residents in the same rotation. RESULTS: faculty completed 2.4 (SD=1.2) P-SCOs per month during the study period. Each resident received 1.1 (SD=0.53) P-SCO observations per month. Faculty and residents completed significantly more observations than targeted (p=0.03 and p=0.003, respectively). Two percent of the P-SCOs had no written comments. Less than 3% of the P-SCO comments were non-specific compared with 43% for the global assessments. Residents received, on average, 3.3 times more total, 2.6 times more reinforcing, and 5.3 times more corrective patient care specific comments on the P-SCO than on the global assessment (p<0.001). For the numerical ratings, residents received an average of 4.2 "exceeds expectations" and 1.7 "below expectations" ratings on P-SCOs compared with 2.6 and 0, respectively, on global assessments (p<0.02). CONCLUSION: faculty can feasibly use the P-SCO instrument in a training clinic. Compared with traditional global assessment, the P-SCO provided much more specific feedback information, a better balance of corrective to re-enforcing comments, and a greater spread of ratings related to competency in pharmacotherapy.

Virtual reality, telemedicine, web and data processing innovations in medical and psychiatric education and clinical care.

OBJECTIVE: This article highlights technology innovations in psychiatric and medical education, including applications from other fields. METHOD: The authors review the literature and poll educators and informatics faculty for novel programs relevant to psychiatric education. RESULTS: The introduction of new technologies requires skill at implementation and evaluation to assess the pros and cons. There is a significant body of literature regarding virtual reality and simulation, including assessment of outcomes, but other innovations are not well studied. CONCLUSIONS: Innovations, like other uses of technology, require collaboration between parties and integration within the educational framework of an institution.

From Yoda to Sackett: the future of psychiatry medical student education.

OBJECTIVE: The authors discuss approaches to curricular goals, methods, and assessments in the education of medical students in psychiatry. METHODS: Using current educational principles and opinions on curricular reform in medical student education, an outline for a core curriculum and an individualized approach to medical student education were developed. RESULTS: A curricular outline addressing both content and organization was developed for all students as well as those specifically entering clinical psychiatry, neuroscience research, and primary care. CONCLUSIONS: In addition to a standard core curriculum there should be a tailored approach for certain subsets of students. The core curriculum should be an "ideal minimum" that recognizes the importance of evidence based medicine and is strategically planned and learner focused.

The role of provider attitudes in prescribing antidepressants to older adults: leverage points for effective provider education.

OBJECTIVES: The purpose of this study was to determine if primary care provider knowledge of late-life depression, attitudes about treatment of depression in late life, and experience treating late-life depression affect the likelihood internists would prescribe antidepressants to older patients. METHODS: This study was a primary care provider survey study. From a pool of 456 eligible mailed surveys, 253 providers completed (55% response rate) a survey assessing provider self-reported knowledge about treating late-life depression with antidepressants, their attitudes about older patients' acceptance and response to antidepressant medications, their professional and personal experience with antidepressant medication, and their comfort with prescribing antidepressants to older patients was created for this study. RESULTS: Univariate analyses indicated that 75% of primary care providers were knowledgeable about the use of antidepressant treatment in older people, and 86% said they felt comfortable treating depression in older patients. Multivariate analyses indicated that the decision to treat older patients with antidepressants was largely influenced by time to treat patients, provider belief that antidepressants could treat late-life depression, their comfort with treating late-life depression, and having had older patients respond to antidepressant treatment in the past (R2 = .52, p < .001). CONCLUSIONS: This study shows that attitudinal and experiential factors play an important role in the likelihood that a provider will treat an older, depressed patient with an antidepressant, more so than knowledge about how to prescribe an antidepressant to older patients. Residency programs for primary care practitioners should include education about the efficacy of antidepressant treatment in older people and should involve hands-on experience in treating late-life depression.