Assessor discomfort and failure to fail in clinical performance assessments.

BACKGROUND: Assessment of trainee performance in the workplace is critical to ensuring high standards of clinical care. However, some supervisors find the task to be challenging, and may feel unable to deliver their true judgement on a trainee's performance. They may 'keep MUM' (that is, keep mum about undesirable messages) and fail to fail an underperforming trainee. In this study, we explore the effect of discomfort on assessors. METHODS: Using a survey method, supervisors of trainees in the Australasian College of Dermatologists were asked to self-report experiences of discomfort in various aspects of trainee workplace assessment and for their engagement in MUM behaviours including failure to fail. RESULTS: Sixty-one responses were received from 135 eligible assessors. 12.5% of assessors self-reported they had failed to fail a trainee and 18% admitted they had grade inflated a trainee's score on a clinical performance assessment in the previous 12-month period. Assessors who reported higher levels of discomfort in the clinical performance assessment context were significantly more likely to report previously failing to fail a trainee. The study did not reveal significant associations with assessor demographics and self-reports of discomfort or MUM behaviours. CONCLUSIONS: This study reveals the impact of assessor discomfort on the accuracy of assessment information and feedback to trainees, including as a contributing factor to the failure to fail phenomenon. Addressing assessor experience of discomfort offers one opportunity to impact on the complex and multifactorial issue that failure to fail represents.

Keeping mum in clinical supervision: private thoughts and public judgements.

CONTEXT: The seemingly obvious claim that people prefer to keep mum about undesirable messages - termed 'the MUM effect' - was initially reported in the psychology literature in the 1970s. More recently, it has been discussed in contexts including performance appraisals and the reporting of unsuccessful projects in workplace settings, but only sparsely in educational ones. We wished to review the published literature on the MUM effect in order to understand the implications for clinical assessment. METHODS: We performed a narrative literature review on the MUM effect and clustered findings together into three themes: those that describe what MUM behaviours look like, those that explore potential reasons for the MUM effect and those that consider factors that can influence MUM behaviours. RESULTS: This paper summarises the extensive literature on the MUM effect, including its manifestations and modifiers and discusses how the effect may be used to consider issues faced by many clinical supervisors faced with delivering 'negative' assessment messages to trainees. DISCUSSION: We suggest, that as a pervasive phenomenon, the MUM effect can both help to explain the difficulties that some assessors face when delivering undesirable messages (including feedback or ratings) and offer new insights in how to deal with such issues.

Trainees' perspectives of assessment messages: a narrative systematic review.

OBJECTIVES: This study was designed as a narrative systematic literature review of medical specialist trainees' perspectives of the assessment messages they receive in the context of clinical performance assessments. The aim of the study was to determine if trainees value the information they receive through the formats designed to promote their development and, if not, the reasons for this. METHODS: The authors searched the ERIC, EMBASE, Ovid MEDLINE and PsycINFO databases for articles published up to 16 June 2018 that present original data on trainees' perspectives of the assessment messages they receive in the context of work-based assessments (WBAs) and in-training assessments (ITAs) used within their training programmes. All authors screened 938 abstracts and 139 full-text articles were assessed after this. Descriptions of quantitative data and thematic analysis of qualitative data were used to present the opinions of trainees. RESULTS: Thirty-three articles met the inclusion criteria. Twenty-six articles (79%) described trainees' perspectives in the context of WBA and the remaining articles referred to ITA formats. Wide-ranging opinions were reported. The analysis categorised these into three themes: trainees value developmental assessment messages; trainees become disengaged when assessment messages are not developmental, and trainees' views depend on the environment, the assessor and themselves. Some trainees reported that the assessment messages were valuable and provided input on their performance to guide their development, but many disagreed. In particular, the trainee's own level of engagement with the assessments influenced his or her perspectives on the messages received. CONCLUSIONS: Trainees do not universally perceive that clinical performance assessments provide them with the valuable developmental input on their performance they were designed to do. Factors related to the environment, the assessor and themselves influence their perspectives.

In-training assessments: 'The difficulty is trying to balance reality and really tell the truth'.

BACKGROUND: In-training assessments (ITA) aim to evaluate trainees' progress and give valuable feedback on their performance. Many factors can affect supervisors during their completion of assessments and these can influence the final results recorded. METHODS: This is the second part of a study of supervisors of the Australasian College of Dermatologists (ACD) and presents the qualitative data on their opinions of the ACD ITA process and the influences on their ITA ratings. RESULTS: Supervisors noted the benefits of this assessment tool, together with many limitations. Potential influences upon supervisor ratings included the relationship between the supervisor and trainee and the level of honesty in completing and delivery of the assessment. CONCLUSIONS: Many factors influence supervisors in the completion of the ITA. These include the impact of interpersonal relationships and concerns about the consequences of delivering a negative assessment, which sometimes lead supervisors to modify the assessment they deliver to the trainee. Further research is needed into honesty in assessment judgements.

Dermatology teaching in Australian Medical Schools.

BACKGROUND/OBJECTIVES: Although skin disease and skin cancers cause significant morbidity and mortality in Australia, limited time is dedicated to dermatology teaching in most medical courses. The aim of this study was to define the current state of dermatology teaching in Australian medical schools with a view to developing a national core curriculum for dermatology. METHODS: An electronic questionnaire was circulated to the dermatology teaching leads and relevant medical program coordinators of the 18 medical schools in Australia. RESULTS: Replies were received from 17 medical schools. Dermatology was included as part of the core curriculum in 15 schools. Time set aside for dermatology teaching varied, as reflected by the number of lectures delivered (0-21, mean 5, median 3) and minimum clinics attended (0-10, mean 1.2, median 0). Only four medical schools had a compulsory clinical attachment in dermatology. Furthermore, satisfying requirements in dermatology was mentioned in the university examination regulations in only six schools. Certain core learning outcomes were addressed in most schools, including the structure and function of the skin, common conditions such as atopic dermatitis and psoriasis and cutaneous malignancies. However, there were important omissions, ranging from common problems like dermatophyte infections and drug reactions to the recognition of dermatological emergencies. CONCLUSIONS: These results are a compelling impetus to improve current standards of dermatology teaching, learning and assessment. The introduction of a national core curriculum would provide guidelines for dermatology teaching in medical schools, enabling the more effective utilisation of available time for key learning outcomes.

Supervisor perspectives on the summative in-training assessment.

BACKGROUND: Assessment is a fundamental component of medical education and exists in many formats. In-training assessments are one such example and they serve to provide feedback to learners about their performance during a period of clinical attachment. However, in addition to trainee knowledge and performance, many factors influence the assessment given to a trainee. METHOD: This study used an anonymous survey to investigate the perceptions of supervisors of the influences on their assessments of Australian dermatology trainees, focusing on the summative in-training assessment (SITA) format. RESULTS: A response rate of 41% was achieved. The importance of reporting underperformance and providing feedback to trainees was agreed on, but current limitations in the ability of the tool to do this were noted. Implications for practice are discussed including the education and support of supervisors, consideration of logistical issues, the process of SITA completion and supervisor appointment. Further research into the impact of supervisor concerns about potential challenges to a judgement and hesitations about making negative comments about a trainee are required. Examination of the trainee perspective is also required. CONCLUSION: Quality feedback is essential for learners to guide and improve their performance. Supervisors face many potential influences on their assessments and if these are too great, they may jeopardise the quality of the assessment given. Attention to highlighted areas may serve to improve the process, so allowing trainees to develop into the best clinicians they can be.

Sweaty, smelly hands and feet.

BACKGROUND: Palmoplantar hyperhidrosis, with or without offensive odour (bromhidrosis), can have a devastating effect on a patient's life. The condition usually begins in childhood or adolescence and can impact greatly on education, career choices and social development. OBJECTIVE: This article describes the presentation, investigation and management options for palmoplantar hyperhidrosis. DISCUSSION: Clinical history and examination is often sufficient to make a diagnosis of palmoplantar hyperhidrosis. Fortunately, there are successful treatments available that can provide relief of symptoms.

Digital nerve blocks: More gain with less pain.

Digital nerve blocks are commonly used and effective techniques for achieving anaesthesia of the digit for the purposes of enabling a variety of surgical procedures to be performed. Several techniques have been described including the traditional method, the metacarpal block and the transthecal approach. We favour the traditional technique, and describe a variation of the technique.

Pigmented fungiform papillae on the tongue in an Asian man.

Fungiform papillae of the tongue vary in their appearance. It is not rare for them to be pigmented in black subjects, but this is less common in Asians. We report a case of pigmented fungiform papillae in a 65-year-old Vietnamese man. The patient also had recurrent aphthous ulceration and hepatitis C. Pigmentation affected all fungiform papillae and was asymptomatic. Macrocytosis was noted on full blood examination, while liver function tests were normal. The pigmentation of the fungiform papillae remained stable.

Iontophoresis with glycopyrrolate for the treatment of palmoplantar hyperhidrosis.

To determine the comparative efficacy of tap water iontophoresis to iontophoresis with the anticholinergic glycopyrrolate, we undertook a single-blinded right-left comparison study in 20 patients with palmoplantar hyperhidrosis. Most patients had their palms treated and one patient had the soles treated. We compared the duration of symptom relief following iontophoresis with glycopyrrolate unilaterally to iontophoresis with glycopyrrolate bilaterally. Patients filled in daily efficacy assessment cards. Each palm was rated as 'dry', 'slightly wet', 'moderately wet' or 'very wet'. Following treatment with unilateral tap water iontophoresis, unilateral glycopyrrolate and bilateral glycopyrrolate, patients reported hand dryness for a median of 3, 5 and 11 days, respectively. As the data was paired, treatment differences were analysed using a sign-rank test. Bilateral glycopyrrolate was superior to both unilateral glycopyrrolate and tap water in most patients. Unilateral glycopyrrolate was superior to tap water in most patients. All differences between groups were found to be statistically significant. We postulate that the increased efficacy of bilateral glycopyrrolate when compared with unilateral glycopyrrolate relates to its systemic absorption. We conclude that glycopyrrolate iontophoresis is more effective than tap water iontophoresis in the treatment of palmoplantar hyperhidrosis and that glycopyrrolate iontophoresis has both local and systemic effects on perspiration.

Late-onset warfarin necrosis.

A 43-year-old woman developed tenderness and induration of her thighs and lower abdomen, 56 days after commencing warfarin for aortic and mitral valve replacements. Investigations showed elevated inflammatory markers, mild renal impairment, normal echocardiogram and low protein C and S levels consistent with warfarin therapy. Three weeks later, purpuric areas evolved into large tender haemoserous bullae, which broke down to form ulcers. Histology confirmed the clinical impression of warfarin-induced skin necrosis with dermal and subcutaneous venular thrombi. Despite cessation of warfarin and commencement of heparin, the lesions progressed. When the patient became febrile, blood cultures grew Pseudomonas aeruginosa, which was treated with intravenous imipenem and vancomycin. Wound swabs grew methycillin-resistant Staphylococcus aureus and the antibiotics were changed. The patient developed septic shock and, despite intensive care management, her condition deteriorated and she died 9 weeks after the onset of the skin symptoms.