Teaching the competencies: using observed structured clinical examinations for faculty development.

OBJECTIVES: Gastroenterology (GI) training programs must develop the teaching skills of their faculty and provide feedback to their fellows. Many faculty feel uncomfortable offering feedback or identifying specific areas for improvement to the fellows. We developed an Observed Structured Clinical Exam (OSCE) to assess fellows' skills and provided faculty with specific criteria to rate the fellows' performance. We propose that OSCEs can serve as tools for faculty development in delivering effective feedback. METHODS: Faculty completed a Web-based training module and received written guidelines on giving feedback. Four OSCE stations were completed by each fellow with faculty using standardized checklists to assess the fellows' skills. Afterwards, faculty rated each program component and assessed their comfort level with feedback. RESULTS: Eight faculty members and 10 fellows from 5 GI training programs in NYC participated. 100% of the faculty agreed that feedback is an important learning tool, should include the learner's self-assessment, and that feedback skills could improve with practice. Compared to faculty skills prior to the program, 87.5% of the faculty agreed that they focused more on specific behaviors and 75% agreed that giving negative feedback was now easier. CONCLUSIONS: OSCEs can serve as practicums for faculty development in giving constructive feedback.

Pulmonary embolism and portal vein thrombosis in an immunocompetent adolescent with acute cytomegalovirus hepatitis.

Cytomegalovirus infection is usually asymptomatic or resembles infectious mononucleosis with fever, pharyngitis, arthralgias, lymphadenopathy, and atypical lymphocytosis. Even though primary CMV infection is usually self-limited in healthy individuals, significant complications can develop in immunocompromised patients. Venous or arterial thromboembolic phenomena are uncommon, yet very serious complications of CMV infection. Most published reports describe immunosupressed patients after organ transplantation or in the presence of HIV co-infection. However, thrombotic events in CMV infected immunocompetent individuals may occur. We describe the case of an immunocompetent adolescent with acute cytomegalovirus hepatitis that was complicated with pulmonary embolism and portal vein thrombosis. To our knowledge, this is the first reported case in which these two thrombotic phenomena occurred simultaneously in an adolescent with no obvious predisposing factors for thrombosis in the setting of an acute CMV infection.

Teaching the competencies: using objective structured clinical encounters for gastroenterology fellows.

BACKGROUND AIMS: Objective structured clinical encounters (OSCEs) are used widely to educate and assess the competence of medical students and residents; they generally are absent from fellowship training. The Accreditation Council for Graduate Education has cited OSCEs as a best practice for assessing the 6 core competencies. This article reports on the use of an OSCE to assess the competence of second-year gastroenterology fellows in the difficult-to-assess core competencies: interpersonal and communication skills and professionalism. METHODS: We developed a 4-station, faculty-observed OSCE with 4 standardized patients. Information gathering, relationship development, patient education, and counseling skills were assessed. Professionalism skills assessed included obtaining informed consent, delivering bad news, managing difficult situations, and showing interdisciplinary respect. In each station, faculty and standardized patients completed an 18- to 24-item checklist evaluating fellows' performance and provided feedback to the fellows. Nine fellows and 5 faculty from 4 gastroenterology training programs in NYC participated. RESULTS: Fellows and faculty generally highly rated the realism of the OSCE and favorably rated the OSCE for its difficulty and their overall experience. Across all cases, fellows were rated as receiving "well dones" for 56.4% of the communication items (SD, 18.3%) and for 79.1% of the professionalism items (SD, 16.4%). CONCLUSIONS: Integrating OSCEs into gastroenterology fellowship training may help enhance communication skills and prepare fellows for dealing with difficult clinical situations and provides mechanisms for constructive feedback. OSCEs developed collaboratively can assist in program self-evaluation and reduce costs by sharing resources, in addition to fulfilling Accreditation Council for Graduate Education mandates.

Complications of pregnancy and child development after cessation of treatment with 6-mercaptopurine for inflammatory bowel disease.

PURPOSE: 6-Mercaptopurine (6-MP) has proven efficacy in the therapy of inflammatory bowel disease. Its teratogenicity is demonstrated in animal studies when used at very high doses, whereas human data suggest that 6-MP at maintenance doses is safe. We report the outcome of 72 pregnancies in patients with inflammatory bowel disease who were previously treated with 6-MP with three different doses of 50, 75, and 100 mg/d, for a median duration of 18 months, along with long-term follow-up of the children. METHODS: We have compared the outcome of pregnancies and development of the offspring in the following two groups: group 1, patients with inflammatory bowel disease who conceived 6 months to 22 years after stopping 6-MP (median 72 months); and group 2, patients with inflammatory bowel disease who never received 6-MP prior to conception. All pregnancies were evaluated in terms of outcome: live full-term birth, premature delivery, stillbirth, spontaneous abortion, ectopic pregnancy, and therapeutic dilatation and curettage. Data on children were obtained regarding birth weight, congenital anomalies, and development. RESULTS: Group 1 included 72 pregnancies carried by 29 women. There were 51 live births (4 premature), 16 spontaneous abortions, 1 stillbirth, 2 therapeutic abortions due to abnormal amniocentesis, and 2 ectopic pregnancies. The total incidence of fetal loss was 29.2%. In group 2, 75 women had 140 pregnancies resulting in 120 live births (8 premature), 18 spontaneous abortions, and 2 stillbirths. There were no cases of ectopic pregnancies or abnormal amniocentesis. The total incidence of fetal loss was 14.3%. There was no increase in the incidence of developmental defects when the mothers had been treated with 6-MP prior to pregnancy. CONCLUSIONS: The incidence of fetal loss is higher in women with inflammatory bowel disease who had been previously treated with 6-MP compared with those who had not. Whether this was related to the older age at conception in 6-MP group, longer duration of disease, initially more severe disease, or use of 6-MP we cannot tell.