Accuracy of Spleen Measurement by Medical Residents Using Hand-Carried Ultrasound.

OBJECTIVES: Easily palpable splenomegaly can be identified on physical examination, but it is difficult to detect lesser degrees of splenomegaly. Rapid bedside assessment can be conducted with hand-carried ultrasound. We performed this study to determine whether medical residents could reliably assess spleen size using hand-carried ultrasound after a brief educational intervention. METHODS: Postgraduate year 1 internal medicine residents were shown a brief (45-minute) presentation on ultrasound basics, the use of hand-carried ultrasound, and principles of splenic ultrasound imaging. They practiced on each other, using hand-carried ultrasound to assess spleen size, for 1 hour in the presence of an instructor. Patients with varying degrees of splenomegaly and hospital staff were recruited at Vancouver General Hospital. A sonographer measured spleen size in each participant using conventional ultrasound. Subsequently, the trained residents scanned the participants using hand-carried ultrasound, blinded to the sonographer's measurements and the participants' diagnoses. The instructor was not present during scanning. RESULTS: Twelve first-year residents (8 male and 4 female; mean age ± SEM, 28 ± 1 years; all with limited prior ultrasound training) and 19 patients and staff members (10 male and 9 female; mean age, 60 ± 4 years; body mass index, 24 ± 2 kg/m(2)) were recruited. The greatest longitudinal measurements were 14.0 ± 0.7 cm with conventional ultrasound administered by the sonographer and 13.2 ± 0.9 cm with hand-carried ultrasound administered by the residents (P > .05, not significant). The correlation between conventional and hand-carried ultrasound was r = 0.81 (P < .001). CONCLUSIONS: Internal medicine residents can reliably assess spleen size at the point of care using hand-carried ultrasound with minimal training. Our findings, if replicated in other centers and in different clinical scenarios, may change the way that clinicians examine the spleen.

Estimation of spleen size with hand-carried ultrasound.

OBJECTIVES: Physical examination can identify palpable splenomegaly easily, but evaluating lesser degrees of splenomegaly is problematic. Hand-carried ultrasound allows rapid bedside assessment of patients. We conducted this study to determine whether hand-carried ultrasound can reliably assess spleen size. METHODS: Patients with varying degrees of splenomegaly were studied. Two sonographers blindly measured spleen size in each patient using either a hand-carried or conventional ultrasound device in random order. Sonographers completed a data sheet indicating the adequacy of the image, clinical measurements of enlargement, and confidence in their observations. RESULTS: Sixteen patients (10 male and 6 female; mean age ± SEM, 60 ± 4 years) were recruited. Image quality was adequate or better in all scans with conventional ultrasound and in 15 of 16 scans with hand-carried ultrasound. The greatest longitudinal measurement recorded was statistically equivalent across ultrasound techniques, with mean values of 16.4 cm (95% confidence interval, 14.8-18.0 cm) for conventional ultrasound and 15.8 cm (95% confidence interval, 14.1-17.4 cm) for hand-carried ultrasound. The correlation between measurement techniques was r = 0.89 (P < .0001). Sonographers were somewhat or very confident in the outcomes of all scans with conventional ultrasound and in 15 of 16 cases with hand-carried ultrasound. In general, it took longer for sonographers to obtain images with hand-carried ultrasound. CONCLUSIONS: We have shown that hand-carried ultrasound can be used at the point of care by trained individuals to diagnose splenomegaly. However, hand-carried ultrasound images were less likely to be judged excellent, were accompanied by less diagnostic certainty, and took longer to obtain.

Using television shows to teach communication skills in internal medicine residency.

BACKGROUND: To address evidence-based effective communication skills in the formal academic half day curriculum of our core internal medicine residency program, we designed and delivered an interactive session using excerpts taken from medically-themed television shows. METHODS: We selected two excerpts from the television show House, and one from Gray's Anatomy and featured them in conjunction with a brief didactic presentation of the Kalamazoo consensus statement on doctor-patient communication. To assess the efficacy of this approach a set of standardized questions were given to our residents once at the beginning and once at the completion of the session. RESULTS: Our residents indicated that their understanding of an evidence-based model of effective communication such as the Kalamazoo model, and their comfort levels in applying such model in clinical practice increased significantly. Furthermore, residents' understanding levels of the seven essential competencies listed in the Kalamazoo model also improved significantly. Finally, the residents reported that their comfort levels in three challenging clinical scenarios presented to them improved significantly. CONCLUSION: We used popular television shows to teach residents in our core internal medicine residency program about effective communication skills with a focus on the Kalamazoo's model. The results of the subjective assessment of this approach indicated that it was successful in accomplishing our objectives.

Real time curriculum map for internal medicine residency.

BACKGROUND: To manage the voluminous formal curriculum content in a limited amount of structured teaching time, we describe the development and evaluation of a curriculum map for academic half days (AHD) in a core internal medicine residency program. METHODS: We created a 3-year cyclical curriculum map (an educational tool combining the content, methodology and timetabling of structured teaching), comprising a matrix of topics under various specialties/themes and corresponding AHD hours. All topics were cross-matched against the ACP-ASIM in-training examination, and all hours were colour coded based on the categories of core competencies. Residents regularly updated the map on a real time basis. RESULTS: There were 208 topics covered in 283 AHD hours. All topics represented core competencies with minimal duplication (78% covered once in 3 years). Only 42 hours (15%) involved non-didactic teaching, which increased after implementation of the map (18-19 hours/year versus baseline 5 hours/year). Most AHD hours (78%) focused on medical expert competencies. Resident satisfaction (90% response) was high throughout (range 3.64 +/- 0.21, 3.84 +/- 0.14 out of 4), which improved after 1 year but returned to baseline after 2 years. CONCLUSION: We developed and implemented an internal medicine curriculum map based on real time resident input, with minimal topic duplication and high resident satisfaction. The map provided an opportunity to balance didactic versus non-didactic teaching, and teaching on medical versus non medical expert topics.

Assessing the mini-Clinical Evaluation Exercise in comparison to a national specialty examination.

PURPOSE: To evaluate the reliability and validity of the Mini-Clinical Evaluation Exercise (mini-CEX) for postgraduate year 4 (PGY-4) internal medicine trainees compared to a high-stakes assessment of clinical competence, the Royal College of Physicians and Surgeons of Canada Comprehensive Examination in Internal Medicine (RCPSC IM examination). METHODS: Twenty-two PGY-4 residents at the University of British Columbia and the University of Calgary were evaluated, during the 6 months preceding their 2004 RCPSC IM examination, with a mean of 5.5 mini-CEX encounters (range 3-6). Experienced Royal College examiners from each site travelled to the alternate university to assess the encounters. RESULTS: The mini-CEX encounters assessed a broad range of internal medicine patient problems. The inter-encounter reliability for the residents' mean mini-CEX overall clinical competence score was 0.74. The attenuated correlation between residents' mini-CEX overall clinical competence score and their 2004 RCPSC IM oral examination score was 0.59 (P = 0.01). CONCLUSION: By examining multiple sources of validity evidence, this study suggests that the mini-CEX provides a reliable and valid assessment of clinical competence for PGY-4 trainees in internal medicine.