Synthesis and perspectives from the Ottawa 2022 conference on the assessment of competence.

INTRODUCTION: The Ottawa Conference on the Assessment of Competence in Medicine and the Healthcare Professions was first convened in 1985 in Ottawa. Since then, what has become known as the Ottawa conference has been held in various locations around the world every 2 years. It has become an important conference for the community of assessment - including researchers, educators, administrators and leaders - to share contemporary knowledge and develop international standards for assessment in medical and health professions education. METHODS: The Ottawa 2022 conference was held in Lyon, France, in conjunction with the AMEE 2022 conference. A diverse group of international assessment experts were invited to present a symposium at the AMEE conference to summarise key concepts from the Ottawa conference. This paper was developed from that symposium. RESULTS AND DISCUSSION: This paper summarises key themes and issues that emerged from the Ottawa 2022 conference. It highlights the importance of the consensus statements and discusses challenges for assessment such as issues of equity, diversity, and inclusion, shifts in emphasis to systems of assessment, implications of 'big data' and analytics, and challenges to ensure published research and practice are based on contemporary theories and concepts.

Entrustable professional activities (EPAs) for undergraduate medical education - development and exploration of social validity.

BACKGROUND: The development of entrustable professional activities (EPAs) as a framework for work-based training and assessment in undergraduate medical education has become popular. EPAs are defined as units of a professional activity requiring adequate knowledge, skills, and attitudes, with a recognized output of professional labor, independently executable within a time frame, observable and measurable in its process and outcome, and reflecting one or more competencies. Before a new framework is implemented in a specific context, it is valuable to explore social validity, that is, the acceptability by relevant stakeholders. AIM: The aim of our work was to define Core EPAs for undergraduate medical education and further explore the social validity of the constructs. METHOD AND MATERIAL: In a nationwide collaboration, EPAs were developed using a modified Delphi procedure and validated according to EQual by a group consisting of teachers nominated from each of the seven Swedish medical schools, two student representatives, and an educational developer (n = 16). In the next step, social validity was explored in a nationwide survey. The survey introduced the suggested EPAs. For each EPA, the importance of the EPA was rated, as was the rater's perception of the present graduates' required level of supervision when performing the activity. Free-text comments were also included and analyzed. RESULTS: Ten Core EPAs were defined and validated. The validation scores for EQual ranged from 4.1 to 4.9. The nationwide survey had 473 responders. All activities were rated as "important" by most responders, ranging from 54 to 96%. When asked how independent current graduates were in performing the ten activities, 6 to 35% reported "independent". The three themes of the free text comments were: 'relevant target areas and content'; 'definition of the activities'; and 'clinical practice and learning'. CONCLUSION: Ten Core EPAs were defined and assessed as relevant for Swedish undergraduate medical education. There was a consistent gap between the perceived importance and the certainty that the students could perform these professional activities independently at the time of graduation. These results indicate that the ten EPAs may have a role in undergraduate education by creating clarity for all stakeholders.

Balancing acting and adapting: a qualitative study of medical students' experiences of early clinical placement.

BACKGROUND: Clinical learning experience is an important part of medical education. In the clinical learning environment, students are exposed to various aspects of medical care and may train their skills under supervision. Supervision, in which students' learning needs and the outcomes of placements are met, is essential. The aim of this study was to explore medical students' experiences of the early stages of clinical training. METHODS: In 2021, 18 individual semi-structured interviews were conducted with medical students after their first clinical placements in semester 5. The interviews were transcribed verbatim and analyzed using qualitative content analysis according to Graneim and Lundman. RESULTS: The findings resulted in an overall theme: balancing acting and adapting. Three categories described that the clinical learning environment was a big leap from campus, that personal relationships influenced learning, and that the organization of clinical placements was suboptimal. The students were encouraged to push themselves forward to practice clinical skills. This, however, did not suit all the students; the cautious ones risked becoming passive spectators. The intended learning outcomes were not frequently used; rather, the supervisors asked the students what they had learned, or the students focused on what seemed to be important on the ward. The students tried to adapt to their supervisors' working situation and not to be a burden to them. CONCLUSIONS: Our findings show that the transition from learning on campus was sometimes abrupt, as the students had to switch to a more active learning role. Ad hoc solutions in supervision occurred, which contributed to the experience that educational responsibilities were downgraded and the opportunities for clinical training varied. Rather than trying to change the circumstances, the students opted to adapt to the busy clinical learning environment.

Faculty perceptions of factors that indicate successful educational outcomes of medical students' research projects: a focus group study.

BACKGROUND: A growing number of medical schools have individual scholarly projects as a component of their curricula. The fact that all students, and not only those with research interests, have to carry out a project puts high demands on the projects and their supervision. Evidence is lacking for how to produce scholarly projects with satisfactory outcomes. This study aimed to explore the observations of faculty teachers regarding factors that predict the educational outcomes of medical students' scholarly projects. METHODS: Two focus group interviews were held with seven of the 16 faculty coordinators who were external reviewers of students' research projects. The audio-recorded interview transcripts were analyzed using qualitative content analysis. We employed a constant comparative approach to create categories firmly grounded in the participants' experiences. A successful project was defined as coordinators' perception that the stated learning outcomes were achieved, in terms of students' ability to demonstrate a scientific attitude. RESULTS: Five categories emerged from the data: Supervision, Project setup, Student characteristics, Curriculum structure, and Institutional guidance. The supervisors' experience and availability to students were mentioned as key factors for successful outcomes. Further, a clear aim and adaptation to the time frame were stated to be project-related factors that were also supervisors' responsibilities. Important student-related factors were skills related to scientific writing, taking ownership of and managing the projects, and making use of feedback. Finally, the course requirements, support, and control accomplished by faculty coordinators played important roles. CONCLUSIONS: Contributing factors to achievement of the learning outcomes were supervisors' commitment and experience, and the projects being suitable for the time frame and having a clearly stated research question. Furthermore, the students' prowess at scientific writing, adequate handling of feedback, and ability to assume ownership of the project contributed to the final outcome, as did adherence to curricular instructions.

-A cross-sectional study of clinical learning environments across four undergraduate programs using the undergraduate clinical education environment measure.

BACKGROUND: The clinical learning environment (CLE) influences students' achievement of learning outcomes and the development of their professional behaviors. However, CLEs are not always optimal for learning because of clinical productivity expectations and a lack of support from supervisors. The purpose of this study was to describe and compare students' perceptions of their CLEs across four undergraduate programs. METHODS: This study is cross-sectional. In total, 735 students who were registered in the medical, nursing, physiotherapy, and speech-language pathology (SLP) programs were invited to participate. Data were collected using an online survey, which included demographics and the Undergraduate Clinical Education Environment Measure (UCEEM). The UCEEM consists of 26 items congregated into two overarching dimensions-experiential learning and social participation-with four subscales: opportunities to learn in and through work and quality of supervision, preparedness for student entry, workplace interaction patterns and student inclusion, and equal treatment. RESULTS: In total 280 students (median age 28; range: 20-52; 72% females) returned the questionnaire. The mean total UCEEM score was 98.3 (SD 18.4; range: 91-130), with physiotherapy students giving the highest scores and medical students the lowest. The mean scores for the dimensions experiential learning and social participation for all the students were 62.8 (SD 13.6; range 59-85) and 35.5 (SD 6.2; range 13-45), respectively. Medical students rated the lowest for all subscales. The items receiving the highest ratings concerned equal treatment, whereas those receiving the lowest ratings concerned supervisors' familiarity with the learning objectives. There were few statistically significant differences between the semesters within each program. CONCLUSIONS: The students generally hold positive perceptions toward their CLEs. However, the students from the medical and nursing programs rated their learning environment lower than did the students from the physiotherapy and SLP programs. Importantly, in several aspects, the medical students provided significantly lower ratings for their CLE compared with the students from the other programs. The medical students' low ratings for their supervisors' familiarity with the learning objectives underscore the need to ensure that the prerequisites for optimal supervision are met.

A prospective study for evaluation of structural and clinical validity of the Eating Assessment Tool.

BACKGROUND: The Eating Assessment Tool is a self-rating questionnaire developed to assess symptom severity and treatment efficacy in swallowing disorders. The aim of this study was to investigate the structural validity of the Eating Assessment Tool and whether individual item scores differed between dysphagia secondary to neurological and structural/esophageal disorders, respectively. METHODS: This is a prospective cross-sectional questionnaire study. In total, 200 community-dwelling adults with suspected dysphagia referred for fiberoptic endoscopic examination of swallowing at Karolinska University Hospital, Stockholm, Sweden, completed the S-EAT-10. Patients' medical charts were reviewed in order to establish the type of dysphagia. Principal axis factoring was conducted to examine structural validity, and Mann-Whitney U tests were used to study differences in the S-EAT-10 score patterns between different types of dysphagia. RESULTS: One single factor explained 54% of the total variance in EAT-10 item scores. All ten items loaded substantially or strongly on this factor, supporting the single-factor solution (Cronbach's alpha = 0.90). Structural/esophageal dysphagia was associated with higher scores on six items and with a higher total EAT-10 score. CONCLUSIONS: The EAT-10 yields a unidimensional index of symptom severity in patients with dysphagia. Individual item scores reflect typical symptoms in neurogenic and structural/esophageal dysphagia, supporting its clinical relevance.

Does reality meet expectations? An analysis of medical students' expectations and perceived learning during mandatory research projects.

BACKGROUND: Although much has been written about structure and outcomes of medical students' curricular research projects, less attention has been paid to the expectations on such projects. In order to foster students' scientific understanding and improve the quality of mandatory research projects, we compared students' pre-course expectations with their post-course insights regarding learning and transferable skills. METHODS: A prospective cross-sectional questionnaire study. All students registered on a mandatory 20-week research project course in 2011-2013 were e-mailed questionnaires in the beginning and after the course asking them to rate statements on expectations and perceived learning on a 5-point Likert scale. Of 652 students, 358 (mean age 26 years; range 21-49; 63% females) returned both questionnaires, corresponding to a response rate of 55%. RESULTS: The ratings for expectations as well as perceived learning were highest for learning to search and critically appraise literature. The greatest pre- and post-course differences were indicated for participation in scientific discussions and oral communication. Surprisingly, both pre- and post-course ratings were low for research ethics. The highest post-course ratings regarding skills for future working life were given to items pertaining to understanding the scientific basis of medicine, ability to follow the development of knowledge and to critically integrate knowledge. Female students had higher expectations than male students. Those with a previous university degree had lower ratings of expectations and perceived learning. Students with basic science projects reported higher expectations and higher learning compared to students with other projects. Previous research experience had no significant influence on expectations nor learning. The correlations between post-course ratings of learning and skills showed that problem-solving ability had a relatively high correlation with all skills. CONCLUSIONS: Students had high expectations and perceived the course improved crucial practical skills. However, expectations were not quite met regarding aspects of scientific communication, and hypothesis formulation, likely because these require more extensive practice and feedback. Students should be actively involved in ethical discussions and oral communication should be trained repeatedly as it is an important task of doctors to communicate scientific information to patients and non-experts.

Medical students' research productivity and career preferences; a 2-year prospective follow-up study.

BACKGROUND: Linking undergraduate medical education to scientific research is necessary for the quality of future health care, and students´ individual research projects are one way to do so. Assessment of the impact of such projects is of interest for both educational and research-oriented segments of medical schools. Here, we examined the scholarly products and medical students' career preferences 2 years after a mandatory research project course. METHODS: A prospective cross-sectional questionnaire study. All 581 students registered on a 20-week research project course between September 2010 through September 2012 were e-mailed a questionnaire 2 years after completing the course. RESULTS: In total, 392 students (mean age 27 years; 60% females) responded (67% response rate). 59 students (15%) were co-authors on a scientific paper published in an international journal, 6 students had published in a national journal, and 57 students had co-authored a paper submitted for publication. Totally, 122 scientific papers had been submitted. Moreover, 67 (17%) students had given 107 oral or poster presentations nationally or internationally during the follow-up. Career-wise, 36 students (9%) had been registered as PhD students and an additional 127 students (34%) were planning to register. Those who did not plan doctoral studies were significantly older (p = 0.013) than those who did. However, 35% reported that they would in the coming 5 years prefer to work as clinicians only, and this group was significantly younger than those who envisaged participation in research. There were no significant gender differences. CONCLUSIONS: Approximately a third of the students had authored papers and/or public presentations, and a similar fraction had career plans involving a PhD degree. The results indicate that the project course had a positive impact on continued supervisor-student collaboration on a professional level, but also that strategies to encourage young doctors to perform clinical research may be needed.

Medical students' experiences of their own professional development during three clinical terms: a prospective follow-up study.

BACKGROUND: A modern competency-based medical education is well implemented globally, but less is known about how the included learning activities contribute to medical students' professional development. The aim of this study was to explore Swedish medical students' perceptions of the offered learning activities and their experiences of how these activities were connected to their professional development as defined by the CanMEDS framework. METHODS: A prospective mixed method questionnaire study during three terms (internal medicine, scientific project, and surgery) in which data were collected by using contextual activity sampling system, i.e., the students were sent a questionnaire via their mobile phones every third week. All 136 medical students in the 6th of 11 terms in the autumn of 2012 were invited to participate. Seventy-four students (54%) filled in all of the required questionnaires (4 per term) for inclusion, the total number of questionnaires being 1335. The questionnaires focused on the students' experiences of learning activities, especially in relation to the CanMEDS Roles, collaboration with others and emotions (positive, negative, optimal experiences, i.e., "flow") related to the studies. The quantitative data was analysed statistically and, for the open-ended questions, manifest inductive content analysis was used. RESULTS: Three of the CanMEDs Roles, Medical Expert, Scholar, and Communicator, were most frequently reported while the four others, e.g., the role Health Advocate, were less common. Collaboration with students from other professions was most usual during the 8th term. Positive emotions and experience of "flow" were most often reported during clinical learning activities while the scientific project term was connected with more negative emotions. CONCLUSIONS: Our results showed that it is possible, even during clinical courses, to visualise the different areas of professional competence defined in the curriculum and connect these competences to the actual learning activities. Students halfway through their medical education considered the most important learning activities for their professional development to be connected with the Roles of Medical Expert, Scholar, and Communicator. Given that each of the CanMEDS Roles is at least moderately important during undergraduate medical education, the entire spectrum of the Roles should be emphasised and developed during the clinical years.

Long-Term Follow-Up of Patients with Spasmodic Dysphonia and Improved Voice despite Discontinuation of Treatment.

OBJECTIVE: To evaluate voice function in patients with adductor spasmodic dysphonia (AdSD) who discontinued botulinum toxin (BTX) treatment because they felt that their voice had improved sufficiently. PATIENTS AND METHODS: Twenty-eight patients quit treatment in 2004, of whom 20 fulfilled the inclusion criteria for the study, with 3 subsequently excluded because of return of symptoms, leaving 17 patients (11 males, 6 females) included in this follow-up study. A questionnaire concerning current voice function and the Voice Handicap Index were completed. Audio-perceptual voice assessments were done by 3 listeners. The inter- and intrarater reliabilities were r > 0.80. RESULTS: All patients had a subjectively good stable voice, but with differences in their audio-perceptual voice assessment scores. Based on the pre-/posttreatment auditory scores on the overall degree of AdSD, patients were divided into 2 subgroups showing more and less improvement, with 10 and 7 patients, respectively. The subgroup with more improvement had shorter duration from the onset of symptoms until the start of BTX treatment, and included 7 males compared to only 4 males in the subgroup with less improvement. CONCLUSION: It seems plausible that the symptoms of spasmodic dysphonia may decrease over time. Early intervention and male gender seem to be important factors for long-term reduction of the voice symptoms of AdSD.

[Portfolio - a tool for making learning and competence development visible]. / Portföljen synliggör lärandet och kompetensutvecklingen.

Portfolio used in education can be defined as a collection of documentation of performed learning activities, feedback, and progress. Currently, the documentation is electronic, hence the term e-portfolio is used. The portfolio must have a clear purpose and be aligned with the learning outcomes of the program. To be successfully implemented a portfolio must be an integral part of the education with defined tasks for both the students and the teachers. Students and teacher support in how to use the portfolio is essential especially in the beginning of the program. Learning analytics enables teachers to identify and develop support for students at risk of not achieving the outcomes.

Development and validation of a laryngopharyngeal reflux questionnaire, the Pharyngeal Reflux Symptom Questionnaire.

OBJECTIVE: To develop and validate the Pharyngeal Reflux Symptom Questionnaire (PRSQ), a comprehensive, disease-specific, self-administered questionnaire for laryngopharyngeal reflux (LPR) disease. MATERIAL AND METHODS: The PRSQ was developed based on empirical evidence from a literature review and expert input from physicians and patients and tested in a pilot study. In this validation study, a total of 228 patients were included and classified according to the Reflux Symptom Index (RSI) cut-off score. Patients with an RSI score > 13 were defined as abnormal, i.e. having LPR disease (n = 102), and those with a score between 0 and 13 were defined as normal controls (n = 126). Psychometric properties of the PRSQ were evaluated by exploring the factor structure and by evaluating internal consistency and item convergent and discriminant validity. Convergent and discriminant validity were determined by using the Laryngopharyngeal Reflux-Health Related Quality of Life questionnaire (LPR-HRQL), the RSI and the Short Form-36. RESULTS: The PRSQ was well accepted by the patients. Compliance was satisfactory and missing item rates were low. After item reduction, due to items not being conceptually relevant or scaling errors and/or low factor loadings, a construct was achieved with no scaling errors and high internal consistency (Cronbach's alpha 0.79-0.93). The correlations between the PRSQ and similar dimensions in the RSI and LPR-HRQL were generally strong. Discriminant validity was satisfactory as the questionnaire discriminated between patients with and without LPR disease. CONCLUSION: The PRSQ showed good psychometric properties and may become a valuable instrument for assessing LPR disease.

Validation of the Swedish translation of LPR-HRQL.

BACKGROUND: The aim of this study was to adapt the Laryngopharyngeal Reflux Health- Related Quality of Life questionnaire (LPR-HRQL) to Swedish and evaluate its psychometric properties in patients with suspected laryngopharyngeal reflux (LPR). MATERIAL/METHODS: The psychometric validation included 228 patients with suspected LPR who had previously undergone a 2-level 24-hour pH examination and who answered a mail-distributed set of questionnaires. The patients were divided into 2 comparable groups according to the Reflux Symptom Index (RSI) cut-off score: 126 patients with RSI score between 0-13 (defined as normal) and 102 patients with RSI score >13 (defined as abnormal, i.e. having LPR disease). RESULTS: LPR-HRQL was adapted to Swedish using a formal forward-backward translation method with input from expert groups (patients and physicians). Psychometric properties of the Swedish version of LPR-HRQL were evaluated by using factor analysis to explore the factor structure. Convergent and discriminant validity was determined by using the questionnaires RSI and Short Form-36 (SF-36). The psychometric tests performed fulfilled the criteria for structural integrity, validity and reliability, mostly confirming the results obtained in the original LPR-HRQL version. CONCLUSIONS: The Swedish translated version of LPR-HRQL proved to be a statistically valid instrument with which to assess HRQL in patients with LPR disease, and will be further tested in prospective studies.

A more than 10-year prospective, follow-up study of esophageal and pharyngeal acid exposure, symptoms and laryngeal findings in healthy, asymptomatic volunteers.

OBJECTIVE: To evaluate the development of pharyngeal and esophageal acid exposure, symptoms, and laryngeal findings in previously healthy subjects. MATERIAL AND METHODS: Thirty-three subjects, previously included in a normative pH monitoring study, completed symptom questionnaires, a video laryngoscopic examination, and ambulatory 24-h pharyngeal and esophageal pH monitoring after a mean follow-up of 14 years. RESULTS: Twenty-four subjects (15 F, 9 M, mean age 57 years) completed the study. The number of subjects with pathological esophageal reflux increased from 5 (21%) at baseline to 8 (33%) at follow-up (p=0.23), whereas the proportion with pharyngeal acid exposure of at least 0.1% decreased from 42% to 13% (p=0.04). Heartburn and/or regurgitation developed in 11 of the 24 (46%) subjects and airway symptoms in 10 (42%) subjects. Laryngeal pathology was found in 9 of 23 subjects (39%). Airway symptoms were equally common among subjects with and those without laryngeal findings or with and without pharyngeal reflux. CONCLUSIONS: Esophageal acid exposure increases over time in previously symptom-free, healthy subjects. The increase in airway symptoms or laryngeal abnormalities is not directly related to increased acid exposure.

Effects of total laryngectomy on olfactory function, health-related quality of life, and communication: a 3-year follow-up study.

BACKGROUND: As total laryngectomy results in loss of airflow through the nose, one of the adverse effects for a majority of patients is the reduced or complete loss of olfactory function. However, with the introduction of a new method, the Nasal Airflow-Inducing Maneuver (NAIM), an important technique is available for laryngectomized patients to regain the ability to smell. The purpose of the present study was to assess changes in olfaction, health-related quality of life (HRQL) and communication 3 years after NAIM rehabilitation. METHODS: 18 patients (15 men and 3 women; mean age, 71 years) who had undergone laryngectomy and NAIM rehabilitation were followed longitudinally for 3 years. For comparison an age and gender matched control group with laryngeal cancer treated with radical radiotherapy was included. Olfactory function was assessed using the Questionnaire on Odor, Taste and Appetite and the Scandinavian Odor Identification Test. HRQL was assessed by: 1) the European Organization for Research and Treatment for cancer quality of life questionnaires; and 2) the Hospital Anxiety and Depression Scale. Communication was assessed by the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer. Descriptive statistics with 95% confidence interval were calculated according to standard procedure. Changes over time as well as tests between pairs of study patients and control patients were analyzed with the Fisher nonparametric permutation test for matched pairs. RESULTS: Thirty-six months after rehabilitation 14 of 18 laryngectomized patients (78%) were smellers. There were, with one exception (sleep disturbances), no clinically or statistically significant differences between the study and the control group considering HRQL and mental distress. However, statistical differences (p < 0.001) were found between the study and the control group concerning changes in communication. CONCLUSION: Olfactory training with NAIM should be integrated into the multidisciplinary rehabilitation program after total laryngectomy. Our study shows that patients who were successfully rehabilitated concerning olfaction and communication had an overall good HRQL and no mental distress. Moreover, the EORTC questionnaires should be complemented with more specific questionnaires when evaluating olfaction and communication in laryngectomized patients.

[It's time to define the Swedish Doctor? Lessons learnt from the evaluation of the Finnish undergraduate medical education]. / Dags att definiera vad en svensk doktor ska kunna - Lärdomar av utvärderingen av den finska läkarutbildningen.

The proposal for a new Swedish 6-year undergraduate medical education entails that the Master of Science in Medicine provides the basis for the licence to practice. During 2017-2018, the Finnish National Education Evaluation Center (FINEEC) conducted a nationwide evaluation of their 6-year medical education. Experiences from their evaluation may be useful in the development of the new Swedish undergraduate education. The outcome important to consider in Sweden is defining common core competencies for all newly graduated doctors, a framework for "Swedish Doctor". A curriculum mapping tool to ensure constructive alignment and an organization to oversee how the curriculum is implemented is essential. Further, the universities have to ensure that all students get training in essential clinical skills and that those skills are assessed. Development of the national collaboration similar to that of Finland is encouraged.

[Examination of future colleagues: We need an assessment culture]. / Att examinera blivande kollegor: Vi behöver en bedömningskultur.

How do we know that the newly graduated student have the competencies required to work as a doctor? Assessments are an integral part of a medical program and are also required to be specified in the syllabi. High-quality assessments are in line with both learning outcomes and content of the courses. Complex learning outcomes require different assessment methods, multiple examiners, and psychometric analysis of the results. Further, the assessment criteria have to be known in advance, and feedback to students should be mandatory. It has to be remembered that the most important tool is the assessor himself, rather than the tools used in the assessment. Teachers need education in assessment. A coherent assessment system helps to create blueprint templates and make it possible to assess progression during the education. The link between examinations and patient safety is critical. We will not get a good education and safer care for our patients without creating an assessment culture.

Stress among medical students during clinical courses: a longitudinal study using contextual activity sampling system.

OBJECTIVES: To investigate medical students' experiences of stress and other emotions related to their professional roles, as defined by the CanMEDS framework, by using the Contextual Activity Sampling System (CASS). METHODS: Ninety-eight medical students agreed to participate of whom 74 completed this longitudinal cohort study. Data was collected between 6th and 8th term via CASS methodology: A questionnaire was e-mailed to the participants every 3rd week(21questionnaires/measurements) during clinical rotations and scientific project work term. Emotions were measured by a 7-point Likert scale (e.g., maximum stress = 7). Answers were registered through mobile technology. We used a linear mixed-model regression approach to study the association between stress over time in relation to socio-demographic and learning activities related to CanMEDS roles. RESULTS: Participants completed 1390 questionnaires. Mean stress level over all time points was 3.6. Stress was reported as highest during the scientific project term. Learning activities related to 'Communicator,' 'Collaborator,' 'Scholar,' 'Manager' and 'Professional' were associated with increased stress, e.g. 'Scholar' increased stress with 0.5 points (t(1339)=3.91, p<0.001). A reduced level of stress was associated with 'Health Advocate' of 0.39 points (t(1338)=-2.15, p=0.03). No association between perceived stress and demographic factors, such as gender or age was found. CONCLUSIONS: An association between different learning activities related to CanMEDS Roles and feelings of stress were noted. The CASS methodology was found to be useful when observing learning experiences and might support educational development by identifying course activities linked to stress.

[EPA (Entrustable professional activities) - an international approach to define key tasks that a doctor should be able to perform]. / EPA ­ en modell för att träna och bedöma dagligt läkarjobb.

Entrustable Professional Activities (EPAs) define observable key tasks that a doctor should be able to do independently after having completed a certain level of education. Progression is facilitated by frequent assessments of the defined activities, with increased degree of independence. The observations should be supported by constructive feed-forward. EPA is currently used in several countries both in undergraduate and post graduate education. In the context of pending changes in Swedish legislation regarding undergraduate education qualifications ordinance and medical licensing, a Swedish national work group has begun to define Swedish EPA for the future undergraduate education.

Gene expression changes of inflammatory mediators in posterior laryngitis due to laryngopharyngeal reflux and evolution with PPI treatment: a preliminary study.

HYPOTHESIS: Standard of care in laryngopharyngeal reflux (LPR) is acid suppression therapy. Its treatment efficacy and mechanism of action are not well documented. No objective study investigating the molecular patterns of inflammation in LPR or in response to proton pump inhibitor (PPI) treatment has been accomplished. We hypothesized that gene expression levels of mediators of inflammation -- interleukin 6 (IL6), interleukin 8 (IL8), interleukin 1a (IL1a), interleukin 1b (IL1b), transforming growth factor beta 1 (TGFbeta1), vascular endothelial growth factor (VEGF), fibroblast growth factor-2 (FGF2), and tumor necrosis factor alpha (TNFalpha) -- in posterior larynx tissue would be increased in those with diagnosed LPR and would be then reduced with PPI treatment. STUDY DESIGN: Prospective uncontrolled trial. METHODS: Biopsies from the posterior larynx were taken from 25 participants with LPR before and after a 10-week period with rabeprazole (40 mg). RNA isolation and real-time PCR was used to measure gene expression levels. RESULTS: No significant differences were measured for any of the cytokines, either for the entire participant group (n = 25) or for the subset of participants who did not have a previous history of PPI usage (n = 15). In those participants who had a history of PPI usage (n = 10), a significant increase in gene expression levels post medication was measured for TGFbeta1 (P = .0396), VEGF (P = .0216), IL8 (P = .0297), after adjusting for compliance, subjective improvement, and reflux severity. CONCLUSIONS: Our findings are provocative and speak to the unresolved understanding of the pathophysiology of LPR, its diagnosis, and its differences from gastroesophageal reflux disease.