Difficulties in Residency: An Examination of Clinical Rotations and Competencies Where Family Medicine Residents Most Often Struggle.

BACKGROUND AND OBJECTIVES: Remediation in residency is expensive; however, most research has focused on general approaches to remediation, with minimal investigation into whether there are patterns to the competencies or rotations that are most difficult for residents. Acquiring this information may improve future physician training and potentially reduce the frequency of resource-intensive remediation. We aimed to determine the competencies and rotations most challenging for family medicine residents, as defined by the number of assessments with flags (one or more competencies indicated as less than satisfactory). METHODS: A secondary data analysis of archived resident files from a large Canadian family medicine residency program was conducted. Residents from six cohorts were reviewed (N=393) and flags on the in-training evaluation reports (ITERs) and summative periodic progress reports were recorded and summarized with descriptive statistics. RESULTS: One hundred forty-one residents (36%) received at least one flag during training. Rotations where learners received the most flags were: internal medicine (average 1.52±4.82 flags), urban family medicine (average 1.48±4.18), and obstetrics (average 1.07±3.80). For residents having at least one flag, competencies causing most difficulty included: professionalism (21.4%), clinical decision making (17.8%), and teamwork and communication (15.5%). CONCLUSIONS: The file review identified coronary care unit, internal medicine, obstetrics, and general surgery as those rotations (adjusted for length) where family medicine residents most often struggled. Furthermore, deficient clinical knowledge was not one of the main reasons that residents are flagged. These findings may inform programs about where to target resident supports and resources.

Skills, Practice Patterns, and Knowledge of Canadian Family Physician Endoscopists.

BACKGROUND AND OBJECTIVES: In Canada, few family physicians (FPs) perform endoscopy. Conflicting evidence exists on the quality of endoscopy performed by Canadian FPs, which may be explained by differing skillsets of these endoscopists. The objective of this study was to perform the first exploration of the practice, skills, and knowledge of Canadian FP endoscopists. METHODS: A cross-sectional survey, including direct knowledge test, was used. RESULTS: Twenty Canadian FP endoscopists completed the survey. Ninety-five percent practice outside urban centres, all perform gastroscopies, and 85% perform colonoscopies and polypectomies. These endoscopists are performing about 32 procedures per month. They are using split bowel preparations, performing rectal retroflexion, and tattooing advanced lesions, all characteristics of a quality endoscopist or program. Self-identified knowledge gaps identified included caring for patients with inflammatory bowel disease and staging rectal cancer. Direct testing found gaps in describing Barrett's esophagitis and managing anticoagulated patients who require endoscopy. CONCLUSIONS: Canadian FP endoscopists appear to be providing quality endoscopic exams and should be supported and encouraged to continue to provide care of rural Canadian patients with gastrointestinal concerns. Future training and continuing education events aimed at this group of endoscopists should target identified knowledge gaps.

Procedural Knowledge and Skills of Residents Entering Canadian Family Medicine Programs in Alberta.

BACKGROUND AND OBJECTIVES: Incoming family medicine (FM) residents start residency with different levels of procedural training. Understanding their baseline skill level is necessary to plan the educational experiences and teaching methods that will provide the desired knowledge, skills, and attitudes related to performing medical procedures. METHODS: A survey of 69 procedures based on the core list issued by the College of Family Physicians of Canada was administered to incoming residents in Alberta (Calgary and Edmonton FM programs). The survey intended to identify the levels of training and confidence acquired for each listed procedure before residency, and plans to perform each of the procedures in future independent practice. RESULTS: A total of 146 residents from both programs responded to the survey (82% response rate). Of the 69 procedures evaluated, 15 (21.7%) had been previously performed at least five times by 50% or more residents. Only five procedures were rated by 80% or more of the residents as being able to perform independently or to teach to others: simple suture, infiltration of local anesthetic, intramuscular injection, cryotherapy of skin lesions and Pap smear. More male residents than female residents felt confident in performing 10 procedures, while female residents were more confident in performing Pap smears. Rural residents felt more confident to perform 22 procedures than their urban colleagues. CONCLUSIONS: This information demonstrates limited prior training in procedures among entering residents, and provides guidance to FM programs to develop teaching interventions to achieve competence in those procedural skills seen as necessary for family physicians.

Giving curriculum planners an edge: using entrance surveys to design family medicine education.

OBJECTIVE: To pilot a survey of family medicine residents entering residency, describing their exposure to family medicine and their perspectives related to their future intentions to practise family medicine, in order to inform curriculum planners; and to test the methodology, feasibility, and utility of delivering a longitudinal survey to multiple residency programs. DESIGN: Pilot study using surveys. SETTING: Five Canadian residency programs. PARTICIPANTS: A total of 454 first-year family medicine residents were surveyed. MAIN OUTCOME MEASURES: Residents' previous exposure to family medicine, perspectives on family medicine, and future practice intentions. RESULTS: Overall, 70% of first-year residents surveyed responded (n = 317). Although only 5 residency programs participated, respondents included graduates from each of the medical schools in Canada, as well as international medical graduates. Among respondents, 92% felt positive or strongly positive about their choice to be family physicians. Most (73%) indicated they had strong or very strong exposure to family medicine in medical school, yet more than 40% had no or minimal exposure to key clinical domains of family medicine like palliative care, home care, and care of underserved groups. Similar responses were found about residents' lack of intention to practise in these domains. CONCLUSION: Exposure to clinical domains in family medicine could influence future practice intentions. Surveys at entrance to residency can help medical school and family medicine residency planners consider important learning experiences to include in training.

Death is not always a failure: outcomes from implementing an online virtual patient clinical case in palliative care for family medicine clerkship.

BACKGROUND: The dying patient is a reality of medicine. Medical students, however, feel unprepared to effectively manage the complex end-of-life (EOL) management issues of the dying patient and want increased experiential learning in Palliative Care. AIMS: To address the need for more formal curriculum in EOL care, we developed and implemented an online virtual patient (VP) clinical case in Palliative Care into the 2010-2011 Year Three Family Medicine Clerkship rotation curriculum. METHODS: A mixed-method design was used to measure the change in knowledge and perceived preparedness level in EOL care before and after completing the online VP case. A survey collected qualitative descriptions of the students' educational experience of using this case. RESULTS: Ninety five percent (130/137) of the students voluntarily consented to have their results analyzed. The group knowledge score (n=127) increased significantly from a pre-course average of 7.69/16±2.27, to a post-course average of 10.02/16±2.39 (p<0.001). The students' self-assessed comfort level increased significantly with all aspects of EOL management from pre-course to post-course (p<0.001). Nearly, 91.1% of the students rated the VP realism as 'Good to Excellent', 86% rated the case as educationally beneficial. Nearly 59.3% of students felt emotionally engaged with the VP. Qualitative feedback found that the case content was very useful and realistic, but that the interface was sometimes awkward to navigate. CONCLUSIONS: The online VP case in Palliative Care is a useful teaching tool that may help to address the need for increased formal Palliative Care experience in medical school training programs.

Persistent expression of Notch2 delays gonadotrope differentiation.

Normal pituitary gland development requires coordination between maintenance of progenitor cell pools and selection of progenitors for differentiation. The spatial and temporal expression of Notch2 during pituitary development suggested that it could control progenitor cell differentiation in the pituitary. Consistent with this idea, Notch2 is not expressed in Prop1 mutants, and anterior pituitary progenitors in Prop1 mutants appear to be unable to transition from proliferation to differentiation properly, resulting in anterior lobe failed cell specification and evolving hypoplasia. To test the function of Notch2 directly, we used the alphaGSU subunit promoter to express activated NOTCH2 persistently in pre-gonadotropes and pre-thyrotropes of transgenic mice. At birth, there is a small reduction in the population of fully differentiated thyrotropes and almost no fully differentiated gonadotropes. The temporal and spatial expression of Hey1 suggests that it could be a mediator of this effect. Gonadotropes complete their differentiation program eventually, although expression of LH and FSH is mutually exclusive with NOTCH2 transgene expression. This demonstrates that activated Notch2 is sufficient to delay gonadotrope differentiation, and it supports the hypothesis that Notch2 regulates progenitor cell differentiation in the pituitary gland.

Mutations in a novel gene, NHS, cause the pleiotropic effects of Nance-Horan syndrome, including severe congenital cataract, dental anomalies, and mental retardation.

Nance-Horan syndrome (NHS) is an X-linked disorder characterized by congenital cataracts, dental anomalies, dysmorphic features, and, in some cases, mental retardation. NHS has been mapped to a 1.3-Mb interval on Xp22.13. We have confirmed the same localization in the original, extended Australian family with NHS and have identified protein-truncating mutations in a novel gene, which we have called "NHS," in five families. The NHS gene encompasses approximately 650 kb of genomic DNA, coding for a 1,630-amino acid putative nuclear protein. NHS orthologs were found in other vertebrates, but no sequence similarity to known genes was identified. The murine developmental expression profile of the NHS gene was studied using in situ hybridization and a mouse line containing a lacZ reporter-gene insertion in the Nhs locus. We found a complex pattern of temporally and spatially regulated expression, which, together with the pleiotropic features of NHS, suggests that this gene has key functions in the regulation of eye, tooth, brain, and craniofacial development.

Mutations in PHF6 are associated with Börjeson-Forssman-Lehmann syndrome.

Börjeson-Forssman-Lehmann syndrome (BFLS; OMIM 301900) is characterized by moderate to severe mental retardation, epilepsy, hypogonadism, hypometabolism, obesity with marked gynecomastia, swelling of subcutaneous tissue of the face, narrow palpebral fissure and large but not deformed ears. Previously, the gene associated with BFLS was localized to 17 Mb in Xq26-q27 (refs 2-4). We have reduced this interval to roughly 9 Mb containing more than 62 genes. Among these, a novel, widely expressed zinc-finger (plant homeodomain (PHD)-like finger) gene (PHF6) had eight different missense and truncation mutations in seven familial and two sporadic cases of BFLS. Transient transfection studies with PHF6 tagged with green fluorescent protein (GFP) showed diffuse nuclear staining with prominent nucleolar accumulation. Such localization, and the presence of two PHD-like zinc fingers, is suggestive of a role for PHF6 in transcription.