Diversity Audit of Medical School Examination Questions.

Phenomenon: This article reports the under-researched presentation of demographic, social, and economic diversity in medical school examination questions. Approach: The present study audited 3,566 pre-clinical and clinical multiple-choice and short answer examination questions in the same year (2018) from three medical schools in two continents to review the diversity of patients portrayed. The audit was based on an extension of Critical Race Theory beyond race and ethnicity to include pertinent social determinants of health. Findings: Patients were presented in 1,537 (43.1%) of the audited examination questions. Apart from age (89.4%) and binary genders (93.9%), other diversity characteristics were rarely portrayed (ethnicity 7.2%, relationship status 1.9%, sexual identity 1.1%, socio-economic status 0.5%, geographic residence 0.1%, disability 0.1%), or not at all (non-binary genders; residency status; religion/spirituality). Insights: While presenting excessive and unnecessary patient characteristics in examination questions should be avoided, the absence of many diversity aspects may reduce examination authenticity and defeat the teaching of diversity in medicine. Medical schools should consider a routine audit and reasonable improvement of the diversity features of patients in examination questions to support teaching and learning activities addressing patients' diversity.

Realist evaluation of faculty development for medical educators: What works for whom and why in the long-term.

PURPOSE: Realism is a perspective in which entities exist independently of being perceived or independently of our theories about them. The realist framework with its principle of explanatory causation was used for an in-depth exploration of faculty development (FD) since, despite the widespread investment in FD, the evidence that it enhances the effectiveness of teaching in the long-term is still limited. The study aimed to develop realist theories that explain the connections between contexts (C), mechanisms (M) and outcomes (O) to find out what works for whom and why in FD. METHODS: Purposive sampling was used to select two medical schools from each of the four UK regions (total 8 of the 33 UK medical schools) for interview of a faculty development coordinator and a medical educator at each school. Sixteen interviews were carried out. Data were coded and summarized under contexts, mechanisms, and outcomes (CMO) to derive realist theories. RESULTS: We identified contexts that facilitated FD mechanisms of engagement, motivation, positive perception and professionalization, which led to educators' outcomes of improved confidence, competence, credibility and career progression. CONCLUSION: Four realist theories, which support the effectiveness of FD in the long-term, were derived, enabling recommendations for FD stakeholders.

Recurrent pelvic organ prolapse: International Urogynecological Association Research and Development Committee opinion.

INTRODUCTION AND HYPOTHESIS: This committee opinion paper summarizes available evidence about recurrent pelvic organ prolapse (POP) to provide guidance on management. METHOD: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development Committee was formed. The literature regarding recurrent POP was reviewed and summarized by individual members of the subcommittee. Recommendations were graded according to the 2009 Oxford Levels of Evidence. The summary was reviewed by the Committee. RESULTS: There is no agreed definition for recurrent POP and evidence in relation to its evaluation and management is limited. CONCLUSION: The assessment of recurrent POP should entail looking for possible reason(s) for failure, including persistent and/or new risk factors, detection of all pelvic floor defects and checking for complications of previous surgery. The management requires individual evaluation of the risks and benefits of different options and appropriate patient counseling. There is an urgent need for an agreed definition and further research into all aspects of recurrent POP.

Faculty development for educators: a realist evaluation.

The effectiveness of faculty development (FD) activities for educators in UK medical schools remains underexplored. This study used a realist approach to evaluate FD and to test the hypothesis that motivation, engagement and perception are key mechanisms of effective FD activities. The authors observed and interviewed 33 course participants at one UK medical school in 2012. An observed engagement scale scored participants' engagement while interviews explored motivation for attendance, engagement during the course and perception of relevance/usefulness. Six months later, using the realist framework, 12 interviews explored impact on learning outcomes/behavioural changes, the mechanisms that led to the changes and the context that facilitated those mechanisms. The authors derived bi-axial constructs for motivation, engagement and perception from two data-sources. The predominant motivation was individualistic rather than altruistic with no difference between external and internal motives. Realist evaluation showed engagement to be the key mechanism influencing learning; the contextual factor was participatory learning during the course. Six months later, engagement remained the key mechanism influencing learning/behavioural changes; the context was reflective practice. The main outcome reported was increased confidence in teaching and empowerment to utilise previously unrecognised teaching opportunities. Individual motivation drives FD participation; however engagement is the key causal mechanism underpinning learning as it induces deeper learning with different facilitating contexts at various time points. The metrics of motivation, engagement and perception, combined with the realist framework offers FD developers the potential to understand 'what works for whom, in what context and why'.

Mixed urinary incontinence: international urogynecological association research and development committee opinion.

BACKGROUND AND AIM: The definition as well as the treatment of women with mixed urinary incontinence (MUI) is controversial. Since women with MUI are a heterogeneous group, the treatment of MUI requires an individual assessment of the symptom components: stress urinary incontinence, urinary urgency, urgency urinary incontinence, urinary frequency, and nocturia. The purpose of this paper is to summarize the current literature and give an evidence-based review of the assessment and treatment of MUI. METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the diagnosis and management of MUI was drafted based on a literature review. After evaluation by the entire IUGA R&D Committee, revisions were made, and the final document represents the IUGA R&D Committee Opinion on MUI. RESULTS: This R&D Committee Opinion reviews the literature on MUI and summarizes the assessment and treatment with evidence-based recommendations. CONCLUSIONS: The diagnosis of MUI encompasses a very heterogeneous group of women. The evaluation and treatment requires an individualized approach. The use of validated questionnaires is recommended to assess urinary incontinence symptoms and effect on quality of life. Conservative therapy is suggested as a first-line approach; if surgery is contemplated, urodynamic investigation is recommended. Women undergoing surgical treatment for MUI need to be counselled about the possibility of persistence of urinary urgency, frequency and urge incontinence even if stress urinary incontinence is cured.

A systematic review of faculty development activities in family medicine.

BACKGROUND: Faculty development (FD) has been defined as a planned programme to prepare institutions and faculty members for their roles in the areas of teaching, research, administration and career management. However, there are few generalisable evaluations of FD activities available to help family medicine FD planners to choose the most effective training strategies. AIM: To assess the evidence for the effectiveness of family medicine FD activities. METHOD: Six electronic databases were searched from 1980 to 2010 and included all articles on FD interventions in family medicine. Hand searching was also undertaken. RESULTS: A total of 4520 articles were identified, 46 fulfilled the search criteria and were reviewed across three domains: (a) Context, i.e. setting, participation and funding. (b) Content/Process, i.e. theoretical framework, focus of intervention/learning outcomes, types of FD intervention and instructional methods. (c) Evaluation using Freeth et al's adaptation of Kirkpatrick's outcome levels. CONCLUSION: FD activities appear highly valued by the participants, leading to changes in learning and behaviour. Changes in organisational practice and student learning were not frequently reported. The continued success of family medicine FD will depend on the contextual approach/collegial support, adaptability of the programmes, robust evaluation and adequate funding in terms of resources and time.

How to confidently teach EBM on foot: development and evaluation of a web-based e-learning course.

BACKGROUND: Scarcity of well-trained clinical tutors is a key constraint in integrating teaching of evidence-based medicine (EBM) into clinical activities. OBJECTIVES: We developed a web-based educational course for clinical trainers to confidently teach EBM principles in everyday practice. Its e-learning modules defined the learning objectives and incorporated video clips of practical and effective EBM teaching methods for exploiting educational opportunities in six different clinical settings. METHODS: We evaluated the course with clinical tutors in different specialties across six European countries using a questionnaire to capture learning achievement against preset objectives. RESULTS: Among 56 tutors, 47 participants (84%) improved their scores from baseline. The mean pre-course score was 69.2 (SD=10.4), which increased to 77.3 (SD=11.7) postcourse (p<0.0001). The effect size was moderate with a Cohen's d of 0.73. CONCLUSIONS: An e-learning approach incorporating videos of applied EBM teaching and learning based on real clinical scenarios in the workplace can be useful in facilitating EBM teaching on foot. It can be integrated in the continuing professional development programmes for clinical trainers.

'Where are you really from?': a qualitative study of racial microaggressions and the impact on medical students in the UK.

OBJECTIVE: To explore graduate-entry medical students' experiences of racial microaggressions, the impact of these on learning, performance and attainment, and their views on how these can be reduced. DESIGN: Qualitative study using semistructured focus groups and group interviews. SETTING: UK. PARTICIPANTS: 20 graduate-entry medical students were recruited using volunteer and snowball sampling; all students self-identified as being from racially minoritised (RM) backgrounds. RESULTS: Participants reported experiencing numerous types of racial microaggressions during their time at medical school. Students' accounts highlighted how these impacted directly and indirectly on their learning, performance and well-being. Students frequently reported feeling uncomfortable and out of place in teaching sessions and clinical placements. Students also reported feeling invisible and ignored in placements and not being offered the same learning opportunities as their white counterparts. This led to lack of access to learning experiences or disengagement from learning. Many participants described how being from an RM background was associated with feelings of apprehension and having their 'guards up', particularly at the start of new clinical placements. This was perceived to be an additional burden that was not experienced by their white counterparts. Students suggested that future interventions should focus on institutional changes to diversify student and staff populations; shifting the culture to build and maintain inclusive environments; encouraging open, transparent conversations around racism and promptly managing any student-reported racial experiences. CONCLUSION: RM students in this study reported that their medical school experiences were regularly affected by racial microaggressions. Students believed these microaggressions impeded their learning, performance and well-being. It is imperative that institutions increase their awareness of the difficulties faced by RM students and provide appropriate support in challenging times. Fostering inclusion as well as embedding antiracist pedagogy into medical curricula is likely to be beneficial.

Multicenter inter-examiner agreement trial for the validation of simplified POPQ system.

INTRODUCTION AND HYPOTHESIS: The primary aim of this study was to evaluate the inter-examiner agreement of a previously described simplified pelvic organ prolapse quantification (S-POP) system in a multicenter, prospective, randomized, blinded fashion. Pelvic organ prolapse quantification (POPQ) system's use in daily practice is hampered due to perceived complexity and difficulty of use. The S-POP was introduced in order to make the POPQ user-friendly and increase its usage (Swift et al. in Int Urogynecol J 17(6):615-620, 2006). METHODS: Five hundred eleven subjects underwent two separate pelvic exams in random order by two blinded examiners employing the S-POP at 12 centers around the world. Data were compared using weighted kappa statistics. RESULTS: The weighted kappa statistics for the inter-examiner reliability of the S-POP were 0.87 for the overall stage, 0.89 and 0.81 for the anterior and posterior vaginal walls, 0.82 for the apex/cuff 0.89, and 0.84 for the cervix and vaginal fornix, respectively. CONCLUSION: There is an almost perfect inter-examiner agreement of the S-POP system for the overall stage and each point within the system.

Modelling of psychosocial and lifestyle predictors of peripartum depressive symptoms associated with distinct risk trajectories: a prospective cohort study.

Perinatal depression involves interplay between individual chronic and acute disease burdens, biological and psychosocial environmental and behavioural factors. Here we explored the predictive potential of specific psycho-socio-demographic characteristics for antenatal and postpartum depression symptoms and contribution to severity scores on the Edinburgh Postnatal Depression Scale (EPDS) screening tool. We determined depression risk trajectories in 480 women that prospectively completed the EPDS during pregnancy (TP1) and postpartum (TP2). Multinomial logistic and penalised linear regression investigated covariates associated with increased antenatal and postpartum EPDS scores contributing to the average or the difference of paired scores across time points. History of anxiety was identified as the strongest contribution to antenatal EPDS scores followed by the social status, whereas a history of depression, postpartum depression (PPD) and family history of PPD exhibited the strongest association with postpartum EPDS. These covariates were the strongest differentiating factors that increased the spread between antenatal and postpartum EPDS scores. Available covariates appeared better suited to predict EPDS scores antenatally than postpartum. As women move from the antenatal to the postpartum period, socio-demographic and lifestyle risk factors appear to play a smaller role in risk, and a personal and family history of depression and PPD become increasingly important.

Prevention and management of ureteric injuries.

Ureteric injury is one of the most serious complications of gynaecological surgery with important medico-legal considerations. This review is aimed at understanding the anatomy of the ureter, sites of ureteric injuries, types and causes of injury, simple preventive measures and management.

Instructions to authors for case reporting are limited: a review of a core journal list.

BACKGROUND: Case reports are frequently published in the health care literature, however advice on preparing such reports using the "instructions to authors" pages of journals is alleged to be limited. However, to our knowledge, this has not been formally evaluated. As roles of case reports may vary according to the case and the clinical specialities, one might expect the advice to authors to vary according to journal clinical grouping. METHODS: We surveyed the current advice available to authors of case reports from 'instructions to authors' pages of a core collection of 249 journals ('Hague' list). These were examined and compared for advice or recommendation on writing case reports. Of these, 163 (65%) published case reports and provided instructions on this publication type. Data were extracted on items of style and content of case reports, using a piloted data extraction form. RESULTS: Journals that published case reports were grouped into medical (n = 81, 50%), surgical (n = 38, 23%) and generic or multidisciplinary (n = 44, 27%) categories. There was a difference among the medical, surgical and generic or multidisciplinary journals in the maximum number of words and pages allowed but no difference in the number of figures, tables, references, authors, abstract or synopsis, indexing or key words and consent. Additionally, there was no statistically significant difference among the three different categories of journals regarding the content of the case reports. CONCLUSIONS: Of the journals reviewed, we found that 'instructions to authors' pages provided limited and varied information for preparing a case report. There is a need for consensus, and more consistent guidance for authors of case report.

Preventable hospital mortality: learning from retrospective case record review.

OBJECTIVE: To determine the proportion of hospital deaths associated with preventable problems in care and how they can be reduced. DESIGN: A two phase before and after evaluation of a hospital mortality reduction programme. SETTING: A district general hospital in Warwickshire, England. PARTICIPANTS: In Phase 1, 400 patients who died in 2009 at South Warwickshire NHS Foundation Trust had their case notes reviewed. In Phase 2, Trust wide measures were introduced across the whole Trust population to bring about quality improvements. MAIN OUTCOME MEASURES: To reduce the crude mortality and in effect the risk adjusted mortality index (RAMI) by 45 in the three years following the start of the programme, from 145 in 2009 to 100 or less in 2012. RESULTS: In total, 34 (8.5%) patients experienced a problem in their care that contributed to death. The principal problems were lack of senior medical input (24%), poor clinical monitoring or management (24%), diagnostic errors (15%) and infections (15%). In total, 41% (14) of these were judged to have been preventable (3.5% of all deaths). Following the quality improvement programme, crude mortality fell from 1.95% (2009) to 1.56% (2012) while RAMI dropped from 145 (2009) to 87 (2012). CONCLUSION: A quality improvement strategy based on good local evidence is effective in improving the quality of care sufficiently to reduce mortality.

Urinary tract injuries at caesarean section: prevention and management.

This article focuses on predisposing risk factors and mechanism of injury for urinary tract injuries at caesarean section. Tips on prevention of injury are followed by a detailed discussion of the management options when injury occurs.