Obstetric and gynecologic ultrasound curriculum and competency assessment in residency training programs: consensus report.

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multi-Society Task Force to develop a consensus-based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency-assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at or close to 75% for each, and obtaining a set of five ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the Task Force expects that the criteria set forth in this document will evolve with time. The Task Force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency-assessment process. Incorporating this training curriculum and the competency-assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Interprofessional education for students of the health professions: the "Seamless Care" model.

"Seamless Care" was one of 21 grants awarded by Health Canada to inform policymakers of the effectiveness of interprofessional education in promoting collaborative patient-centred practice among health professionals. The "Seamless Care" model of interprofessional education was designed with input from three Faculties at Dalhousie University (Medicine, Dentistry and Health Professions). The design was grounded in relevant learning theories--Social Cognitive Theory, Self-efficacy, Situated Learning theory and Constructivism. The intervention was informed by principles of active learning, problem-based learning, reflection and role modeling. The primary goal of Seamless Care was to develop students' interprofessional patient-centred collaborative skills through experiential learning. Fourteen student teams, each including one student from medicine, nursing, pharmacy, dentistry and dental hygiene, learned with, from and about each other while they were mentored in the collaborative care of patients transitioning from acute care to the community. Student teams providing collaborative care assisted patients experiencing a chronic illness to become more active in managing their health through development of self-management and decision-making skills. This paper describes the Seamless Care model of interprofessional education and discusses the theoretical underpinnings of this experiential model of interprofessional education designed to extend classroom-based interprofessional education to the clinical setting.

Linking assessment to learning: a new route to quality assurance in medical practice.

BACKGROUND: If continuing professional development is to work and be sensible, an understanding of clinical practice is needed, based on the daily experiences of doctors within the multiple factors that determine the nature and quality of practice. Moreover, there must be a way to link performance and assessment to ensure that ongoing learning and continuing competence are, in reality, connected. Current understanding of learning no longer holds that a doctor enters practice thoroughly trained with a lifetime's storehouse of knowledge. Rather a doctor's ongoing learning is a 'journey' across a practice lifetime, which involves the doctor as a person, interacting with their patients, other health professionals and the larger societal and community issues. OBJECTIVES: In this paper, we describe a model of learning and practice that proposes how change occurs, and how assessment links practice performance and learning. We describe how doctors define desired performance, compare actual with desired performance, define educational need and initiate educational action. METHOD: To illustrate the model, we describe how doctor performance varies over time for any one condition, and across conditions. We discuss how doctors perceive and respond to these variations in their performance. The model is also used to illustrate different formative and summative approaches to assessment, and to highlight the aspects of performance these can assess. CONCLUSIONS: We conclude by exploring the implications of this model for integrated medical services, highlighting the actions and directions that would be required of doctors, medical and professional organisations, universities and other continuing education providers, credentialling bodies and governments.

Community family medicine teachers' perceptions of their teaching role.

OBJECTIVES: Our study explored community preceptors' perceptions of their teaching role, to better understand effective ambulatory and community-based teaching. METHODS: Bandura's social cognitive theory and Schön's notion of reflective practice guided conceptual development of an interview exploring preceptors' views of their role, teaching goals, teaching techniques, student assessment practices, factors affecting teaching and learning, and balance of patient and student needs. Preceptors reflected also on a significant personal teaching experience. A total of 17 highly student-rated preceptors participated. A trained interviewer conducted each interview; all were transcribed and subjected to content analysis. RESULTS: Preceptors (male, 14; female, 3) described learner-centred approaches, setting goals jointly with the student. Demonstration, guided practice, observation and feedback were integral to the experience. Preceptors saw student comfort in the environment as key to effective learning; they attempted to maximize students' learning and breadth of experience. They wanted students to understand content, "know-how" and "being a family physician". Patients remained the primary responsibility, but learners' needs were viewed as compatible with that responsibility. Many preceptors perceived a professional responsibility as "role models". CONCLUSIONS: Preceptors recognized the dynamic environment in which they taught students, and they described strategies which demonstrated how they adapted their teaching to meet the needs of the learner in that environment. These teachers combined learner-centred approaches with sound educational practices, broad learning experiences, attention to student learning and concern for development of professional expertise and judgement. These findings may assist faculty development in family medicine, and other disciplines, in providing effective ambulatory care teaching.

A comparison of standard-setting procedures for an OSCE in undergraduate medical education.

PURPOSE: To compare four standard-setting procedures for an objective structure clinical examination (OSCE). METHODS: A 12-station OSCE was administered to 84 students in each of the final (fourth-) year medical classes of 1996 and 1997 at Dalhousie University Faculty of Medicine. Four standard-setting procedures (Angoff, borderline, relative, and holistic) were applied to the data to establish a cutoff score for a pass/fail decision. RESULTS: The procedures yielded highly inconsistent results. The Angoff and borderline procedures gave similar results; however, the relative and holistic methods gave widely divergent results. The Angoff procedure yielded results reliable enough to use in decision making for a high-stakes examination, but would have required more judges or more stations. CONCLUSIONS: The Angoff and borderline procedures provide reasonable and defensible approaches to standard setting and are practical to apply by non-psychometricians in medical schools. Further investigation of the other procedures is needed.

Motivation in medical education: how theory can inform our practice.

Medical educators seek to understand and facilitate learners' motivations to acquire the skills, knowledge, values, and attitudes that will prepare them for life-times of learning and providing care to their patients and communities. Yet faculty are often challenged by experiences with learners who appear unmotivated, or who seem to value goals other than those the faculty espouse. Understanding what motivates learners may help educators appreciate the complex environment in which motivations are formed, and the sometimes-hidden influences upon motivation that may explain learners' attitudes and behaviors. In this brief essay, the author discusses some of the current theories about motivation and describes how they might relate to the education of physicians. She also explores the too-frequent disparities between medical schools' stated goals for learners and what is actually taught or rewarded by faculty. Although motivation is multifaceted, involving learners and the entire learning environment, there are strategies that may be used to strengthen students' motivations to achieve important goals.

Comparing achievement on the Medical Council of Canada Qualifying Examination Part I of students in conventional and problem-based learning curricula.

PURPOSE: To compare the levels of achievement on the Medical Council of Canada (MCC) Qualifying Examination Part I of students in conventional and problem-based learning (PBL) curricula. METHOD: Students in three classes (1995, 1996, and 1997) took the MCC Qualifying Examination Part I upon completing their MD degrees. This examination tests core knowledge in the major disciplines and clinical reasoning skills. Candidates' scores were masked to protect confidentiality. Total scores, individual discipline scores, and pass/fail proportions were compared among the classes. RESULTS: The PBL classes of 1996 and 1997 performed better on the psychiatry component than did the 1995 conventional class (p = .001); the 1997 class also exceeded the 1995 and 1996 classes in preventive medicine and community health scores (p = .001). No difference emerged in other disciplines, clinical reasoning scores, total multiple-choice question scores, or the proportions of successful candidates. CONCLUSION: PBL and conventional curriculum graduates performed similarly, except in psychiatry and preventive medicine and community health, where PBL graduates scored higher.

Primary care physicians' perceptions of adolescent pregnancy and STD prevention practices in a Nova Scotia county.

INTRODUCTION: This study was carried out to determine the predisposing, enabling, and reinforcing factors related to practice behaviors in the prevention of adolescent pregnancy and sexually transmitted diseases (STDs), and to assess physicians' "ideal" history taking and service provision versus their actual practice in this clinical area. METHODS: Twenty-six of 37 physicians in a single county in Nova Scotia took part in a face-to-face interview. RESULTS: Analysis of predisposing factors found that, for seven of 10 areas related to knowledge of the epidemiology of adolescent pregnancy and STDs, fewer than 50% of male physicians were able to give correct responses. All physicians believed this to be an important area for prevention, and 89% that prevention is possible, but only 62% believed that their own prevention efforts are effective. Respondents were about equally likely to view schools and physicians as having responsibility for prevention of adolescent pregnancy and STDs. Significant enabling factors included high levels of perceived personal comfort and skill, but time factors and opportunities to interact with adolescents sufficiently frequently to carry out prevention were seen as barriers. Most physicians (68%) agreed that the physician fee schedule was a negative reinforcing factor. Male physicians and those in rural practice were significantly more likely to have larger gaps between those preventive practices they saw as desirable and those they actually performed.

PIP: In 1992, the reported Nova Scotia provincial rate for Chlamydia trachomatis genital infection was 15/1000 for girls and 2/1000 for boys, whereas rates for County A were 12/1000 for girls and 1/1000 for boys. The predisposing, enabling, and enforcing factors related to practice behaviors in the prevention of adolescent pregnancy and sexually transmitted diseases (STDs) were determined in face-to-face interviews to assess 26 physicians' ideal history taking and service provision versus their actual practice. Beliefs, attitudes, and enabling and reinforcing factors were assessed using a 5-point Likert scale. Interviews were completed between July 7 and August 31, 1994, with 26 doctors, of whom 20 were men (median age, 39 years) and 6 were women (median age, 35 years). The number of years in practice was 12. Fewer than 50% of male physicians were able to answer 7 of the 10 questions in relation to predisposing factors in prevention of adolescent pregnancy and STDs. 89% of the physicians believed that adolescent pregnancy and STDs are preventable, only 62% believed their own efforts to be effective in prevention. 85% of the physicians believed that schools had a responsibility to provide sex education, while 81% considered the role of parents in avoiding pregnancy and STDs crucial. 85% agreed that they were comfortable about talking with adolescents about sexuality, but only 36% felt that their medical school education had provided adequate preparation and 46% cited lack of time. While two-thirds agreed that female adolescents often made appointments for pregnancy prevention, only 23% said that girls did the same for STD prevention and 12% said that boys did. 68% of the physicians claimed that the current Medical Services Insurance fee schedule discouraged them from talking to adolescents about prevention. The lowest rate of agreement was with questions about sexual orientation (69%) and sexual practices (62%). The median score difference between believing that questions should be asked in the history and actually asking those questions was 0.0 for women and 2.0 for men (p = 0.04).

Basic sciences in problem-based learning and conventional curricula: students' attitudes.

The purpose of this study was to compare the attitudes toward basic sciences of students in a preclinical problem-based curriculum and a conventional lecture-based curriculum at the end of their second year of medical school. The results showed that the PBL class had more positive attitudes toward basic sciences than students in the conventional class. These results may reflect a learning environment where students meet many scientist role models as teachers and where basic science is learnt in the context of clinical problems.

Surveillance of loperamide ingestions: an analysis of 216 poison center reports.

BACKGROUND: Loperamide was approved for nonprescription use in 1988. While efficacy is well documented, there are few data on loperamide overdose and management. METHODS: Eight poison centers participated in a prospective study enrolling 216 patients. RESULTS: Where the amount ingested was known, it ranged from 0.03 to 0.94 mg/kg. One- to 3-year-olds were involved in 57.9% of ingestions. Ingestion was unintentional in 182 cases (84.3%), including 59 patients with therapeutic errors (27.3% of all cases). Dispensing cup errors were implicated in 23 cases; 15 patients assumed the dispensing cup was the unit of measure. No symptoms developed in 63.0%; 27.8% had related symptoms. No related symptoms were life-threatening, and no fatalities occurred. The most frequent symptoms were drowsiness (15.7%), vomiting (4.2%), and abdominal pain or burning (3.7%). The frequency of related symptoms was compared in patients receiving the most frequently utilized decontamination modalities: ipecac alone, activated charcoal alone, lavage and activated charcoal, and ipecac and activated charcoal. Compared to the 112 patients who received no decontamination, only the ipecac-treated group demonstrated a significant reduction in the frequency of related symptoms; 13.9% of patients given ipecac alone (without other gastric decontamination) had related symptoms compared to 33.0% of patients who received no decontamination. Three patients received naloxone for CNS symptoms related to loperamide; two responded and the response of the third was unknown. CONCLUSION: Within the range of doses implicated in this study (up to 0.94 mg/kg), there were no life threatening clinical effects and no fatalities. Development of a management protocol is complicated by the absence of a predictable clinical response in each dose range. The data suggest that children over six months with single acute ingestions up to 0.4 mg/kg, and possibly higher, can be safely managed at home, without gastric decontamination.

Increasing physician involvement In cholesterol-lowering practices: The role of knowledge, attitudes and perceptions.

The study evaluated a multifaceted educational intervention systematically designed to increase physician involvement in cholesterol-lowering practices. We hypothesized that knowledge, perceptions and behaviours would be enhanced in participating physicians, compared with controls. Method: Fifty-one family physicians were assigned randomly to three groups; the two experimental groups attended a training workshop, received physician and patient education materials and ongoing consultant support. One experimental group also received a "cuing" intervention. The control group received no interventions. Outcome measures included knowledge and attitude scores, self-efficacy perceptions, and physician dietary counselling behaviour. Measures were taken at pretest, 6 weeks and 15 months later. Results: Intervention group physicians achieved significantly higher knowledge scores than the control group at the six-week test; the differences disappeared at 15 months. Attitudes, self-reported practices and overall self-efficacy scores were similar across groups. Within group variation was highly significant. Physician dietary counselling scores were significantly higher in the intervention groups (p = 0.0001). Some associations were seen among knowledge, attitude, self-efficacy and dietary counselling scores. Conclusion: Physician behaviour change in cholesterol reduction may not depend entirely upon knowledge, attitudes and perceptions.

Comparing students' attitudes in problem-based and conventional curricula.

PURPOSE: To compare the attitudes of students in a new problem-based learning (PBL) medical curriculum and in the previous conventional curriculum after the second curriculum year, prior to the clinical clerkships. The authors hypothesized that the PBL students would have more favorable attitudes toward their learning environment, social issues in medicine, and their curriculum. METHOD: The students in the classes of 1995 (conventional curriculum) and 1996 (PBL curriculum) at the Dalhousie University Faculty of Medicine were asked to complete two main questionnaires and a few additional items that measure attitudes. The admission variables of the two classes were equivalent. Their attitude ratings were compared using t-tests. RESULTS: Response rates averaged 87% (73 of 84 students) and 68% (57 of 84) for the PBL and conventional classes, respectively. The students in the PBL class had more positive attitudes toward their learning environment on the subscales for enthusiasm and authoritarianism (i.e., they rated their curriculum more favorably for democratic decision making); they were less positive on the student-interaction subscale. No significant difference emerged between the two classes on any subscale for attitudes about social issues in medicine. The PBL students reported more positive attitudes toward their curriculum. CONCLUSION: The study results support the superiority of the PBL curriculum regarding the students' attitudes toward their medical education.

Living with haemophilia and HIV/AIDS: support and coping.

This paper describes sources and types of support, appraisal of support, and use of social support as a strategy for coping with Acquired Immune Deficiency Syndrome (AIDS)-related stresses. Thirty people with haemophilia, 23 family caregivers and 17 bereaved relatives participated. The study was conducted in two stages: individual interviews and mailed questionnaires. The key coping strategies used were 'normalizing personal relationships' and 'seeking informational support'. Informational support was provided by health professionals and practical aid by relatives. Respondents reported insensitivity, prejudice and avoidance from others. Participants needed peers for emotional and affirmational support, and professionals for informational support. The preferred intervention was support groups, co-led by professionals and peers.

Five-year multicenter retrospective review of cyclobenzaprine toxicity.

Cyclobenzaprine (CBP) has a cyclic structure similar to amitriptyline. In overdose, CBP has been suggested to produce the cardiovascular and neurologic toxicity found with the cyclic antidepressants. To examine this possibility, a retrospective chart review of all cases of CBP exposure reported to five regional poison centers was performed for the years 1989-93. There were a total of 750 charts identified for CBP exposure, of which 523 had data sufficient for evaluation. There were 121 polydrug ingestions leaving 402 pure CBP ingestions. Ages ranged from 7 mo to 77 yrs, with a mean of 20 yrs; 26% were 6 yrs or less. Females comprised 63% of the patient group. No deaths occurred. Dysrhythmias beyond sinus tachycardia were infrequent, and none were life-threatening. No seizures occurred. Common effects were lethargy, sinus tachycardia, and agitation, and both hypertension and hypotension were seen. All symptomatic cases with a known time of ingestion were symptomatic within 4 h of ingestion. Doses ingested ranged from 5-1000 mg, with a mean of 133 mg. Asymptomatic and symptomatic patients had a mean dose ingested of 45 mg and 183 mg, respectively. Treatment was primarily gastrointestinal (GI) decontamination and supportive care. Other therapies required were mechanical ventilation, dopamine, fluid bolus, sedation, and foley catheter. Symptoms requiring treatment beyond GI decontamination did not occur with ingestions less than 100 mg. In conclusion, cyclobenzaprine does not appear to produce the life-threatening cardiovascular or neurologic effects of the cyclic antidepressants in doses less than 1 g. Lethargy and anticholinergic effects are prominent, though serious toxicity is infrequent.

A response to the ACME-TRI report: the Dalhousie problem-based learning curriculum.

With the class of 1996, Dalhousie University Faculty of Medicine instituted a totally revised curriculum. The revisions transformed an entirely traditional curriculum to a student-centred curriculum, which is based on learning in context, and incorporates a problem-based approach to the entire curriculum. This paper describes our experience in the actual implementation of our revised curriculum, in the context of the Association of American Medical Colleges Assessing Change in Medical Education--The Road to Implementation (ACME-TRI) Report.