Intraoperative physician assessment during total hip arthroplasty correlates with DXA parameters.

PURPOSE: Orthopedic surgeons can assess bone status intraoperatively and recommend skeletal health evaluation for patients with poor bone quality. Intraoperative physician assessment (IPA) at the time of total knee arthroplasty correlates with preoperative DXA-measured bone mineral density (BMD). This study evaluated IPA during total hip arthroplasty (THA) as a quantitative measure of bone status based on tactile assessment. METHODS: This retrospective analysis identified 60 patients (64 hips) undergoing primary THA who had IPA recorded in the operative report and a DXA within 2 years before surgery. Intraoperatively, two surgeons assessed bone quality on a 5-point scale (1 = excellent; 5 = poor). IPA score was compared to DXA BMD and T-score, 3D Shaper measurements, WHO classification, FRAX scores, radiographic Dorr classification, and cortical index. RESULTS: There was a strong correlation between the IPA score and lowest T-score, WHO classification, and FRAX major and hip fracture scores (r = ± 0.485-0.622, all p < 0.001). There was a moderate correlation between IPA score and total hip BMD and 3D Shaper measurements, including trabecular volumetric BMD, cortical surface BMD, and cortical thickness (r = ± 0.326-0.386, all p < 0.01). All patients with below-average IPA scores had osteopenia or osteoporosis by DXA. CONCLUSION: IPA during THA is a simple, valuable tool for quantifying bone status based on tactile feedback. This information can be used to identify patients with poor bone quality that may benefit from skeletal status evaluation and treatment and provide intraoperative guidance for implant selection. Orthopedic surgeons can assess bone health at the time of surgery. Intraoperative physician assessment (IPA) is a bone quality score based on surgeons' tactile assessment that correlates strongly with the lowest T-score, WHO classification, and FRAX fracture risk. IPA can guide surgical decision-making and future bone health treatment.

Refresh of a Clinical Skills Assessment for Physician Trainees.

Purpose: The Royal Australasian College of Physicians (RACP) oversees physician training across Australia and Aotearoa New Zealand. Success in a written examination and clinical skills assessment (known as the clinical examination) at the mid-point of training is a requirement to progress from basic to advanced training. The clinical examination had evolved over many years without a review process. This paper describes the approach taken, the changes made and the evaluation undertaken as part of a formal review. Methods: A working party that included education experts and examiners experienced in the assessment of clinical skills was established. The purpose of the clinical examination and competencies being assessed were clarified and were linked to learning objectives. Significant changes to the marking and scoring approaches resulted in a more holistic approach to the assessment of candidate performance with greater transparency of standards. Evaluation over a 2-year period was undertaken before the adoption of the new approach in 2019. Results: In 2017 testing of a new marking rubric occurred during the annual examination cycle which confirmed feasibility and acceptability. The following year an extensive trial utilising the new marking rubric and a new scoring approach took place involving 1142 examiners, 880 candidates and 5280 scoresheets which led to some minor modifications to the scoring system. The final marking and scoring approaches resulted in unchanged pass rates and improved inter-rater reliability. Feedback from examiners confirmed that the new marking and scoring approaches were easier to use and enabled better feedback on performance for candidates. Conclusion: The refresh of the RACP clinical examination has resulted in an assessment that has clarity of purpose, is linked to learning objectives, has greater transparency of expected standards, has improved inter-rater reliability, is well accepted by examiners and enables feedback on examination performance to candidates.

Socioeconomic status is associated with process times in the emergency department for patients with chest pain.

Objective: Emergency department length of stay (EDLOS) is linked to crowding and patient outcomes whereas worse prognosis in low socioeconomic status remains poorly understood. We studied whether income was associated with ED process times among patients with chest pain. Methods: This was a registry-based cohort study on 124,980 patients arriving at 14 Swedish EDs between 2015 and 2019 with chest pain as their chief complaint. Individual-level sociodemographic and clinical data were linked from multiple national registries. The associations between disposable income quintiles, whether the time to physician assessment exceeded triage priority recommendations as well as EDLOS were evaluated using crude and multivariable regression models adjusted for age, gender, sociodemographic variables, and ED-management circumstances. Results: Patients with the lowest income were more likely to be assessed by physician later than triage recommendations (crude odds ratio [OR] 1.25 (95% confidence interval [CI] 1.20-1.29) and have an EDLOS exceeding 6 h (crude OR 1.22 (95% CI 1.17-1.27). Among patients subsequently diagnosed with major adverse cardiac events, patients with the lowest income were more likely to be assessed by a physician later than triage recommendations, crude OR 1.19 (95% CI 1.02-1.40). In the fully adjusted model, the average EDLOS was 13 min (5.6%) longer among patients in the lowest income quintile, 4:11 [h:min], (95% CI 4:08-4:13), compared to patients in the highest income quintile, 3:58 (95% CI 3:56-4:00). Conclusions: Among ED chest pain patients, low income was associated with longer time to physician than recommended by triage and longer EDLOS. Longer process times may have a negative impact due to crowding in the ED and delay diagnosis and timely treatment of the individual patient.

Unsolicited Patient Complaints Identify Physicians with Evidence of Neurocognitive Disorders.

OBJECTIVES: Determine whether words contained in unsolicited patient complaints differentiate physicians with and without neurocognitive disorders (NCD). METHODS: We conducted a nested case-control study using data from 144 healthcare organizations that participate in the Patient Advocacy Reporting System program. Cases (physicians with probable or possible NCD) and two comparison groups of 60 physicians each (matched for age/sex and site/number of unsolicited patient complaints) were identified from 33,814 physicians practicing at study sites. We compared the frequency of words in patient complaints related to an NCD diagnostic domain between cases and our two comparison groups. RESULTS: Individual words were all statistically more likely to appear in patient complaints for cases (73% of cases had at least one such word) compared to age/sex matched (8%, p < 0.001 using Pearson's χ2 test, χ2 = 30.21, df = 1) and site/complaint matched comparisons (18%, p < 0.001 using Pearson's χ2 test, χ2 = 17.51, df = 1). Cases were significantly more likely to have at least one complaint with any word describing NCD than the two comparison groups combined (conditional logistic model adjusted odds ratio 20.0 [95% confidence interval 4.9-81.7]). CONCLUSIONS: Analysis of words in unsolicited patient complaints found that descriptions of interactions with physicians with NCD were significantly more likely to include words from one of the diagnostic domains for NCD than were two different comparison groups. Further research is needed to understand whether patients might provide information for healthcare organizations interested in identifying professionals with evidence of cognitive impairment.

Preoperative assessment of ovarian tumors using a modified multivariate index assay.

BACKGROUND: Preoperative differentiation between benign and malignant masses can be challenging. The aim of this research was to evaluate the performance of a modified multivariate index assay (MIA) in detecting ovarian cancer and to compare the effectiveness of gynecologist assessment, cancer antigen (CA) 125, and MIA for identifying ovarian masses with high suspicion of malignancy. RESULTS: This prospective observational study included 150 women with ovarian masses who underwent surgery in the Maternity Teaching Hospital from December 2014 to May 2016. Preoperative estimation of modified MIA, assessment by a gynecologist, and CA 125 level correlated with the surgical histopathology. A modified MIA was implemented because of lack of access to the software typically used. Among 150 enrolled women there were 30 cases of malignancy, including 8 cases (26%) of early-stage ovarian cancer and 22 cases (74%) of late-stage cancer. MIA showed high specificity (96.7%) in detecting cancer and a sensitivity of 70%, with a positive predictive value of 84% and a negative predictive value of 92.8%. No significant differences were detected between the MIA results and the histopathology results (P = 0.267). For early-stage ovarian cancer, the sensitivity of MIA was 100% compared with 75% for CA 125 alone. CONCLUSION: MIA seems to be effective for evaluation of ovarian tumors with higher specificity and positive predictive value than CA 125 while maintaining high negative predictive value and with only a slightly lower overall sensitivity. For evaluation of early-stage ovarian cancer, MIA showed a much higher sensitivity that markedly outperformed CA 125 alone. This modified MIA strategy may be particularly useful in low resource setting.

Clinical measurements versus patient-reported outcomes: analysis of the American Shoulder and Elbow Surgeons physician assessment in patients undergoing reverse total shoulder arthroplasty.

BACKGROUND: The American Shoulder and Elbow Surgeons (ASES) score is composed of a patient-reported portion and a physician assessment. Although the patient-reported score is frequently used to assess postoperative outcomes after shoulder arthroplasty, no previous studies have used the physician-assessment component. This study evaluated the relationship of the ASES physician-assessment measurements with patient-reported shoulder and general health outcomes. METHODS: A retrospective review of a prospectively collected multicenter database was used to analyze patients who underwent primary reverse total shoulder arthroplasty (RTSA) from 2012 to 2015 with a minimum 2-year follow-up. ASES physician-assessment and patient-reported components and 12-Item Short Form Health Survey (SF-12) general health questionnaires were obtained preoperatively and 2 years postoperatively. The relationship between ASES physician measurements with ASES patient-reported outcome (PRO) scores and SF-12 Physical and Mental domain scores was assessed with Pearson correlation coefficients. RESULTS: Included were 74 patients (32 men; mean age, 69.2 years; body mass index, 29.4 kg/m2). Preoperative physician measurements and PRO scores were not significantly correlated. Postoperatively, only the ASES physician-measured active (R = 0.54, P < .01) and passive forward flexion (R = 0.53, P < .01) demonstrated moderate correlation with ASES patient scores. The remaining clinical measurements had no significant correlations with ASES patient or SF-12 scores. During the 2-year period, only improvements in active forward flexion correlated with improvements in ASES patient scores (R = 0.36, P < .01). CONCLUSIONS: Little correlation exists between clinical measurements from the ASES physician component and PROs, including the ASES patient-reported and SF-12 general health surveys, in RTSA patients. Improvement in active forward flexion is the only clinical measurement correlated with PRO improvement at 2 years.

State of the art of chronic spontaneous urticaria in Italy: a multicentre survey to evaluate physicians' and patients' perspectives.

OBJECTIVE: To assess the clinical status of chronic spontaneous urticaria (CSU) and understand treatment approaches in Italy through specialists who treat CSU (dermatologists and allergy specialists) and CSU patients' experience. DESIGN: Multicentre survey. SETTING: Online structured questionnaires (one for physicians and one for patients). PARTICIPANTS: Physicians and patients with CSU in Italy. INTERVENTIONS: None. PRIMARY/SECONDARY OUTCOMES: Physician and patient attitudes/experiences. RESULTS: Survey results from 160 allergy and 160 dermatology specialists show that specialists see a median of 40 (IQR 20-80) patients with CSU/year. While most specialists (56%) know the CSU guidelines, only 27% use them regularly (36% of allergy specialists vs 18% of dermatologists). This is reflected in treatment choices with differences between physicians who use guidelines regularly and those who do not: 91.6% vs 71.7% choose standard-dose, non-sedating antihistamines as first-line treatment; 85.9% vs 56.0% select up-dosing for second-line treatment and 65.3% vs 37.2% add leukotriene receptor antagonists or H2-antihistamines as third-line treatment. The diaries from 1385 patients highlight that, regardless of treatment regimen, 29.4% of currently treated patients are refractory to therapy. Specialists aim to resolve symptoms and only 7.8% report improving quality of life (QoL) as a priority. Only 16.6% of specialists are familiar with and use the Urticaria Activity Score while 46.9% do not know it. Overall, 537 patients with CSU were surveyed (median age 37 years, IQR 30-46; 44.3% men; median disease duration 5 years, IQR 3-20). Approximately 62% confirm that CSU negatively impacts their QoL. Patients also complain of difficulties in getting information and support: <5% of medical centres provide patient support services. CONCLUSIONS: In Italy, the gap between guideline-based care and QoL-related needs in CSU patients affects treatment satisfaction. This information could be used to improve the management of CSU in Italy.

Progression of fibromyalgia: results from a 2-year observational fibromyalgia and chronic pain study in the US.

BACKGROUND: A previous fibromyalgia (FM) research reports that 20%-47% of diagnosed patients may not meet the study definition of FM 1-2 years after diagnosis. The aim of this study was to gain a better understanding of the progression of FM in a geographically diverse cohort over a 2-year time period. METHODS: This cohort study followed 226 subjects recruited online to assess FM and chronic widespread pain (CWP) diagnosis stability over time. At enrollment (baseline), subjects provided informed consent, completed an online questionnaire consisting of the London Fibromyalgia Epidemiology Study Screening Questionnaire to screen for CWP (bilateral pain above/below waist lasting ≥1 week in the past 3 months), visited a site for physician evaluation for FM, and completed a questionnaire with validated patient-reported outcome instruments. Subjects were classified into mutually exclusive groups: FM+CWP+ (screened positive for CWP and received physician diagnosis of FM), FM-CWP+ (screened positive for CWP but did not receive physician diagnosis of FM), and FM-CWP- (screened negative for CWP). Approximately 2 years later (follow-up), subjects were reassessed at the same study site and completed a questionnaire with the same patient-reported outcomes. RESULTS: Seventy-six FM+CWP+ subjects completed assessments at both time points; 56 (73.7%) met the FM study definition at follow-up. Twenty subjects no longer met the FM study definition (eleven became FM-CWP- and nine became FM-CWP+). Ten subjects (two from FM-CWP- and eight from FM-CWP+) transitioned into the FM+CWP+ group at follow-up; they reported more tender points and pain interference with sleep and worse physical function at baseline compared with subjects who did not transition to FM+CWP+. Most (76.7%) of the subjects who transitioned into/out of FM+CWP+ experienced changes in CWP, number of positive tender points, or both. CONCLUSION: The results suggest that some FM+CWP+ patients experience fluctuation in symptoms over time, which may reflect the waxing and waning nature of FM and affect diagnosis and treatment.

Assessing interprofessional teamwork: pilot test of a new assessment module for practicing physicians.

INTRODUCTION: Teamwork is a basic component of all health care, and substantial research links the quality of teamwork to safety and quality of care. The TEAM (Teamwork Effectiveness Assessment Module) is a new Web-based teamwork assessment module for practicing hospital physicians. The module combines self-assessment, multisource feedback from members of other professions and specialties with whom the physician exercises teamwork, and a structured review of those data with a peer to develop an improvement plan. METHODS: We conducted a pilot test of this module with hospitalist physicians to evaluate the feasibility and usefulness of the module in practice, focusing on these specific questions: Would physicians in hospitals of different types and sizes be able to use the module; would the providers identified as raters respond to the request for feedback; would the physicians be able to identify one or more "trusted peers" to help analyze the feedback; and how would physicians experience the module process overall? RESULTS: 20 of 25 physicians who initially volunteered for the pilot completed all steps of the TEAM, including identifying interprofessional teammates, soliciting feedback from their team, and identifying a peer to help review data. Module users described the feedback they received as helpful and actionable, and indicated this was information they would not have otherwise received. CONCLUSIONS: The results suggest that a module combining self-assessment, multisource feedback, and a guided process for interpreting these data can provide help practicing hospital physicians to understand and potentially improve their interprofessional teamwork skills and behaviors.

Role for assessment in maintenance of certification: physician perceptions of assessment.

INTRODUCTION: The Royal College of Physicians and Surgeons of Canada modified its Maintenance of Certification (MOC) framework in 2011 to further incentivize assessment activities compared to group and self-learning. The purpose of this study was to explore physician's perceptions of their access to assessment activities, barriers to participation in assessment, and the need for the Royal College to further support its fellows in gaining access to assessment activities. METHODS: A questionnaire-based survey was sent to all participants of the MOC program as part of a program evaluation examining recent changes to the MOC program. RESULTS: 5259 respondents contributed responses. Most physicians were comfortable with the revised framework for assessment while approximately 40% were neutral regarding whether lack of access to self-assessment activities was a problem. Respondents expressed a need for more self-assessment programs particularly those developed outside of Canada. Neither a lack of feedback about performance or discomfort with recording performance gaps was perceived as a barrier to participation in assessment activities. Physician comments were consistent with the quantitative data and elaborated on the need to develop and recognize more assessment activities. DISCUSSION: Physicians accepted the revised MOC program framework but perceived difficulty in accessing assessment programs, activities, and tools. As the framework changed again January 2014, requiring all fellows and MOC program participants to completion of at least 25 credits in each section of the MOC program (including assessment) during their new 5-year MOC cycle, additional resources will be needed to support opportunities for physicians to engage in assessment.

Returning inactive obstetrics and gynecology physicians to clinical practice: the Drexel experience.

INTRODUCTION: Physicians returning to clinical practice after inactivity may face many challenges. Few programs provide reeducation, and data are limited about these experiences. We describe the physician refresher/reentry program at Drexel University College of Medicine, Philadelphia, and the lessons learned in our efforts to facilitate obstetrician-gynecologists' clinical reentry. METHODS: In 2006, Drexel relaunched the Medical College of Pennsylvania's physician reentry course. This structured yet individualized program provides reeducation and assessment for physicians who have left clinical medicine for any reason and are hoping to return. We report the results achieved for 9 obstetrician-gynecologists who successfully completed Drexel's course between November 2006 and November 2012. RESULTS: The 6 men and 3 women had left their practices for different reasons. Seven were reentry candidates, and 2 were remediating; none had left practice for medical negligence. Of the reentering physicians, 5 achieved their goal within 1 month. Of the remediating physicians, 1 achieved his/her goal. DISCUSSION: Through continual self-assessment and participant feedback, we have learned to expand our staff and faculty career advisory roles and seek specialty-specific assessment. Despite our small sample size, Drexel's experience may provide guidance to the growing field of obstetrician/gynecologist reentry in the United States.

Chronic myeloid leukemia patients' adherence to peroral tyrosine kinase inhibitors compared with adherence as estimated by their physicians.

PURPOSE: To evaluate chronic myeloid leukemia (CML) patients' adherence to peroral tyrosine kinase inhibitors in Finland and to compare this with adherence as estimated by their physicians. Other aspects studied included how patients' knowledge of the disease and its treatment influence adherence. MATERIALS AND METHODS: A total of 120 CML patients were contacted between June 2012 and September 2013 in eight secondary or tertiary care hospitals in Finland. Of these, 86 participated in the study. This covers approximately 20% of all Finnish CML patients. The mean age was 57.8 years and 52% were male. Of the patients, 79.1% were using imatinib, 10.5% dasatinib, and 10.5% nilotinib. The patient-reported adherence (experienced adherence) was evaluated using the eight-item Morisky Medication Adherence Scale (MMAS). In addition, the treating physicians were asked to give their subjective opinion on their patients' adherence (observed adherence). The experienced adherence was compared with the observed adherence using a three-level rating system (high, medium, low). All patients were personally interviewed and their demographic data collected. The statistical analysis of the data was based on descriptive statistics presented as frequencies, percentages, means, and medians. The kappa coefficient was calculated between the patient's and the doctor's assessment of adherence. RESULTS: A total of 23% (20/86) of the patients were fully adherent according to the MMAS, while physicians evaluated 94% (80/86) of the patients as fully adherent. The physicians' estimate was too optimistic in 73% of cases. The discrepancy was confirmed by a kappa value of -0.004. The patients' knowledge of the disease and its treatment was poor in all adherence levels. CONCLUSION: The patient-reported adherence to tyrosine kinase inhibitor treatments in Finland was found to be the same as that found in the majority of previous studies. However, there seems to be a very weak agreement between the patient's and the physician's assessment of adherence. This study suggests that physicians overestimate the adherence of CML patients and base their assessment primarily on the clinical treatment response.

Workplace-based assessment for vocational registration of international medical graduates.

INTRODUCTION: Medical regulatory authorities need efficient and effective methods of ensuring the competence of immigrating international medical graduates (IMGs). Not all IMGs who apply for specialist vocational registration will have directly comparable qualifications to those usually accepted. As general licensure examinations are inappropriate for these doctors, workplace-based assessment (WBA) techniques would appear to provide a solution. However, there is little published data on such outcomes. METHODS: All cases of WBA (n = 81) used for vocational registration of IMGs in New Zealand between 2008 and 2013 were collated and analyzed. RESULTS: The successful completion rate of IMGs through the pathway was 87%. The majority (64%) undertook the year of supervised practice and the final assessment in a provincial center. For those unsuccessful in the pathway, inadequate clinical knowledge was the most common deficit found, followed by poor clinical reasoning. DISCUSSION: A WBA approach for assessing readiness of IMGs for vocational registration is feasible. The constructivist theoretical perspective of WBA has particular advantages in assessing the standard of practice for experienced practitioners working in narrow scopes than traditional methods of assessment. The majority of IMGs undertook both the clinical year and the assessment in provincial hospitals, thus providing a workforce for underserved areas.

Trends in physician preferences for and use of sources of medical information in response to questions arising at the point of care: 2009-2013.

INTRODUCTION: Recent information on the preferences and trends of medical information sources for US practicing physicians in the past several years is lacking. The purpose of this study was to identify current format preferences and attitudes of physicians as well as trends over time to provide timely information for use in educational planning. METHODS: A survey instrument was developed and distributed in 2013 to US practicing physicians in several specialties. Data were aggregated and analyzed to understand trends across these physicians. Differences between and among demographic subsets of physicians, such as practice type and location, were observed by the use of inferential statistics. Additionally, using a similar survey fielded in 2009, these findings were analyzed to observe potential changes in the past 4 years. RESULTS: Peer-reviewed journal articles and continuing medical education (CME) are reported to be the most useful sources of medical information by physicians. Non-CME promotional meetings, pharmaceutical sales representatives, and managed care organizations are least useful or influential. Physicians are receiving more clinical questions from patient encounters in 2013 compared to 2009, and spend more time searching for information online. The use of many formats to receive medical information is increasing, including both technology-derived and traditional formats. DISCUSSION: Increases in clinical questions and time spent online indicate a heightened need for efficiencies in searching for medical information. New uses of technology in medical information delivery may allow educators an avenue to meet the rising needs of physicians.

Long-term outcomes of a remedial education program for doctors with clinical performance deficits.

INTRODUCTION: Medical regulatory authorities need reliable methods of assessing and remediating doctors where there are concerns over competence. There's a small but growing literature describing remediation programs and documenting their effectiveness. This article adds to that literature by describing a program associated with the Medical Council of New Zealand (MCNZ) and reporting outcomes for 24 consecutive doctors required to undergo remediation. METHODS: Over the 18-month period covered in this study, 24 doctors were required by the MCNZ to enter remediation after a performance assessment. The data set used in this study was drawn from these 24 consecutive cases and included the nature of concerns, severity of concerns, results of remediation and outcome of a second assessment when such an assessment was ordered. RESULTS: Of 24 doctors who underwent initial assessment, 5 failed to engage with remediation and withdrew from clinical work. A 12-month education remediation program was completed by all remaining 19 doctors. Of these, 13 were considered to be practicing at an acceptable standard at the end of remediation on the basis of sequential supervisor reports. Six doctors were required to have a second performance assessment. Of these, only 1 was considered to be functioning at an acceptable standard. Concurrent health concerns were common among this cohort of doctors. DISCUSSION: Seventy-five percent of doctors who entered remedial education were considered to be practicing at an acceptable standard at the end of remediation. This accords well with international data. A small number of doctors appear to be unresponsive to remediation.

Specialty board certification in the United States: issues and evidence.

BACKGROUND: The American Board of Medical Specialties (ABMS) certification and maintenance of certification (MOC) programs strive to provide the public with guidance about a physician's competence. This study summarizes the literature on the effectiveness of these programs. METHOD: A literature search was conducted for studies published between 1986 and April 2013 and limited to ABMS certification. A modified version of Kirkpatrick's 4 levels of program evaluation included the reaction of stakeholders to certification, the extent to which physicians are encouraged to improve, the relationship between performance in the programs and nonclinical external measures of physician competence, and the relationship of performance in the programs with clinical quality measures. RESULTS: Patients' and hospitals' value of board certification and physician participation in MOC are high. Physicians are conflicted as to whether the effort involved is worth its value. Self-reported evidence shows improvement in knowledge, practice infrastructure, communication with patients and peers, and clinical care. Certification performance is generally related to nonclinical external measures such as types of training, practice characteristics, demographics, and disciplinary actions. In general, physicians who are board certified provide better patient care, albeit the results have modest effect sizes and are not unequivocal. CONCLUSIONS: Certification boards should continuously try to improve their programs in response to feedback from stakeholders, changes in the way physicians practice, as well as the growth in the fields of measurement and technology. Keeping pace with these changes in a responsible and evidence-based way is important.

The United Kingdom's experience with and future plans for revalidation.

Assuring fitness to practice for doctors internationally is increasingly complex. In the United Kingdom, the General Medical Council (GMC) has recently launched revalidation, which has been designed to bring all doctors into a governed environment. Since December 2012, all doctors who wish to practice are required to submit and reflect on supporting documentation against a framework of best practice, Good Medical Practice. These documents are brought together in an annual appraisal. Evidence of practice includes clinical governance activities such as significant events, complaints and audits, continuing professional development and feedback from colleagues and patients. Revalidation has been designed to support professionalism and identify early doctors in difficulty to support their remediation and so assure patient safety. The appraiser decides annually if the doctor has met the standard which is shared with the most senior doctor in the area, the responsible officer (RO). The RO's role is to make a recommendation for revalidation every 5 years for each doctor to the GMC. Revalidation is unique in that it is national, compulsory, involves all doctors regardless of position or training, and is linked to the potentially performance moderating process of appraisal. However, it has a long and troubled history that is shaped by high-profile medical scandals and delays from the profession, the GMC, and the government. Revalidation has been complicated further by rhetoric around patient care and driving up standards but at the same time identifying poor performance. The GMC have responded by commissioning a national evaluation which is currently under development.

Practicing physicians' needs for assessment and feedback as part of professional development.

Recently, more is being learned about the linkages among assessment, feedback, and continued learning and professional development. The purpose of this article is to explore these linkages and to understand how assessment and feedback can guide professional development and related practice change. It includes a brief review of conceptual models that guide learning and practice change in general, related to both formally structured continuing professional development (CPD) sessions and to self-directed individual activities, and draws on these to inform learning and change from assessment and feedback. However, evidence and theory show that using assessment and feedback for learning and change are not naturally intuitive activities. We propose a 4-phase facilitated reflective process for enabling engagement with assessment data and feedback and using it for learning and change, and explore the varied personal and contextual factors which are influential and require consideration. We end with practical implications and suggestions.

Patient self-assessment and physician's assessment of rheumatoid arthritis activity: which is more realistic in remission status? A comparison with ultrasonography.

OBJECTIVE: The objective of this study was to compare disease activity assessed by the patient, the physician and musculoskeletal US in patients with RA in clinical remission. METHODS: We evaluated 69 patients with RA in clinical remission according to their attending rheumatologist. Tenderness and swelling in 28 joints were blindly assessed by patients and physicians. The presence of B-mode and Doppler synovitis was blindly investigated in the above joints. The DAS28 and Simplified Disease Activity Index (SDAI) were calculated. RESULTS: The percentage of patients in remission according to the self-derived DAS28 (26.1%) was significantly less than that according to the physician-derived DAS28 (52.2%) (P < 0.0005). There was no significant difference in the percentage of patients in remission according to the self-derived SDAI (14.5%) and the physician-derived SDAI (11.6%) (P = 0.172). We found moderate agreement between the patient-derived and physician-derived DAS28 and SDAI [intraclass correlation coefficient (ICC) = 0.620 and ICC = 0.678, respectively]. Agreement between patient and physician was better for the tender joint count (TJC; ICC = 0.509) than for the swollen joint count (SJC; ICC = 0.279). The mean (S.D.) count for B-mode synovitis [4.09 (3.25)] was significantly greater than the SJC assessed by both the patient and physician [2 (3.71) and 1.42 (2.03), respectively] (P < 0.0005 and P = 0.033, respectively). We found moderate agreement between the physician-assessed SJC and the joint count for Doppler synovitis (ICC = 0.528). CONCLUSION: Patient-assessed and physician-assessed overall RA activity showed acceptable agreement. Patient self-assessment overestimated disease activity determined by the DAS28. At the patient level, physician-assessed joint swelling showed an acceptable concordance with Doppler US synovitis.

United States medical students' knowledge of Alzheimer disease.

PURPOSE: A knowledge gap exists between general physicians and specialists in diagnosing and managing Alzheimer disease (AD). This gap is concerning due to the estimated rise in prevalence of AD and cost to the health care system. Medical school is a viable avenue to decrease the gap, educating future physicians before they specialize. The purpose of this study was to assess the knowledge level of students in their first and final years of medical school. METHODS: Fourteen participating United States medical schools used e-mail student rosters to distribute an online survey of a quantitative cross-sectional assessment of knowledge about AD; 343 students participated. Knowledge was measured using the 12-item University of Alabama at Birmingham AD Knowledge Test for Health Professionals. General linear models were used to examine the effect of demographic variables and previous experience with AD on knowledge scores. RESULTS: Only 2.5% of first year and 68.0% of final year students correctly scored ten or more items on the knowledge scale. Personal experience with AD predicted higher knowledge scores in final year students (P= 0.027). CONCLUSION: Knowledge deficiencies were common in final year medical students. Future studies to identify and evaluate the efficacy of AD education programs in medical schools are warranted. Identifying and disseminating effective programs may help close the knowledge gap.