Assessment of clinical competencies using clinical images and videos "CIVA".

BACKGROUND: This paper describes an assessment approach of clinical competencies which widens the number of problems and tasks evaluated using videos and images. METHOD: Clinical Image and Video Assessment (CIVA) was used to assess clinical reasoning and decision making of final year medical students. Forty to fifty clinical videos and images supported by rich text vignette and reviewed by subject matter experts were selected based on examination blueprints for analysis. CIVA scores were correlated with OSCE, Direct Observation Clinical Encounter Exam (DOCEE) and written exam scores, using the 2-sided Pearson correlation analysis, and their reliability was analyzed using Cronbach's Alpha Coefficient. Furthermore, students personally evaluated the CIVA using a 5- point Likert scale. RESULTS: CIVA and OSCE scores showed a high correlation (r = 0.83) in contrast with the correlation scores of the written examination (r = .36) and the DOCEE (r = 0.35). Cronbach's Alpha for the OSCE and CIVA for the first batch was 0.71 and 0.78. As for the second batch it was 0.91 and 0.91 respectively. Eighty-two percent of students were very satisfied or satisfied with the CIVA process, contents and quality. CONCLUSIONS: A well constructed CIVA type assessment with a rich authentic vignette and good quality videos and images could be used to assess clinical reasoning and decision making of final year medical students. CIVA is an assessment tool which correlates well with OSCE, compliments the written and DOCEE and is easier to conduct at a possibly reduced cost.

Accuracy of asthma and COPD diagnosis in Australian general practice: a mixed methods study.

BACKGROUND: Spirometry is the 'gold standard' for diagnosing asthma and chronic obstructive pulmonary disease (COPD) but is rarely used in general practice. AIMS: To compare doctor diagnoses with patient reports/spirometry and to determine doctors' perceptions of spirometry. METHODS: Patients prescribed inhaled medication were recruited from 31 practices. Doctor diagnoses were extracted from practice records. Patients completed a questionnaire and spirometry before and after bronchodilator. In-depth interviews were conducted with a sample of doctors. RESULTS: Doctor diagnoses were available for 278 patients: asthma 192 (69%), COPD 38 (14%), asthma/COPD 40 (14%), and eight patients (3%) with other conditions. The diagnosis of asthma was correctly reported by 93% of patients, but only by 61% of those with COPD alone. Among those with both diagnoses, 83% reported asthma and 48% reported COPD. Of those with a diagnosis of COPD, 65% had fixed airflow limitation. Conversely, only 14% of those had been diagnosed with COPD alone. There was no significant difference in reversibility in forced expiratory volume in 1 second between diagnoses. While recognising the value of spirometry in differentiating between asthma and COPD, most general practices only used spirometry in diagnostically difficult cases. CONCLUSIONS: Doctor-diagnosed asthma is accurately reported by patients. However, COPD remains substantially under-diagnosed. Spirometry needs to be more widely used to improve the accuracy of respiratory diagnoses in general practice.

Effect of spirometry and medical review on asthma control in patients in general practice: a randomized controlled trial.

BACKGROUND AND OBJECTIVE: Although guidelines for asthma emphasize the importance of spirometry for continuity and evaluation of care, it is underused in general practice. The objective of this study was to investigate the effect of spirometry and medical review on asthma control in general practice over 12 months. METHODS: Patients were recruited through 31 practices, which were randomly allocated to one of three groups: Group A had 3-monthly spirometry with medical review, Group B spirometry only before and after the trial, and Group C usual care. Asthma control data were analysed by intention to treat using non-parametric tests and logistic regression models fitted to allow for confounders, repeated measures and clustering by practice. RESULTS: The trial was completed by 195 patients (Group A 69, Group B 78, Group C 48). Asthma control improved in all groups during the 12 months trial, most impressively in Group A (odds ratio per 3 months = 1.27, 95% confidence interval: 1.08-1.49, P = 0.004), but the difference between the groups' respective 3-monthly changes was not significant. At 6 months, asthma control in Group A had increased more from baseline than in Groups B + C (P = 0.006). CONCLUSIONS: Regular spirometry with medical review was associated with improved asthma control in general practice patients, while there was less improvement in either the spirometry only or usual care group. The mechanisms of this improvement may include appropriate adjustment of medication and improved compliance.

Do small group workshops and locally adapted guidelines improve asthma patients' health outcomes? A cluster randomized controlled trial.

OBJECTIVE: To improve health outcomes of children and adolescents with asthma using a multifaceted intervention for GPs. METHODS: The design of the study was a cluster randomized controlled trial. GPs were randomized at a practice level in general practice clinics in Melbourne, Australia. Participants were children/adolescents aged 2-14 years with asthma and their caregivers identified from the medical records of participating clinics. Questionnaires were completed by 411 at baseline and 341 at follow-up. The intervention arm (n = 18 GPs) participated in a small group asthma education programme and was provided with locally adapted paediatric asthma guidelines. One control arm (n = 18 GPs) received only the adapted paediatric asthma guidelines, while the other control arm (n = 15 GPs) received an unrelated educational intervention. The outcome measures of the study were children/adolescents and caregivers completed questionnaires about asthma management and control, asthma knowledge and quality of life at recruitment and 6 months later. Ownership of a written asthma action plan (WAAP) was the primary outcome. RESULTS: There was no evidence for changes in ownership of WAAPs between the three study arms. Adolescents in the intervention group reported an improvement in quality of life subscale score 'positive effects' (mean difference = 2.64, P = 0.01), but there was no evidence for an effect of the intervention on other study outcomes among the three study arms. CONCLUSIONS: The intervention was associated with some improvement in quality of life for adolescents. However, overall, the intervention did not translate into increased ownership of WAAPs, control of asthma or improved quality of life.

An interactive workshop plus locally adapted guidelines can improve general practitioners asthma management and knowledge: a cluster randomised trial in the Australian setting.

BACKGROUND: A cluster randomised trial was conducted to determine the effectiveness of locally adapted practice guidelines and education about paediatric asthma management, delivered to general practitioners (GPs) in small group interactive workshops. METHODS: Twenty-nine practices were randomly allocated to one of three study arms. Australian asthma management guidelines were adapted to accommodate characteristics of the local area. GPs in the intervention arm (Group 1, n = 18 GPs) participated in a small group based education program and were provided with the adapted guidelines. One control arm (Group 2, n = 18 GPs) received only the adapted guidelines, while the other control arm (Group 3, n = 15 GPs) received an unrelated education intervention. GPs' knowledge, attitudes and management of paediatric asthma was assessed. RESULTS: Post intervention, intervention arm GPs were no more likely to provide a written asthma action plan, but were better able to assess the severity of asthma attack (Group 1vs Group 2 p = 0.05 and Group 1 vs Group 3 p = 0.01), better able to identify patients at high risk of severe attack (Group 1vs Group 3 p = 0.06), and tended to score higher on the asthma knowledge questionnaire (Group 1 vs Group 2 p = 0.06 and Group 1 vs Group 3 p = 0.2). Most intervention arm GPs felt more confident than control GPs to manage acute asthma attack and ongoing management of infrequent episodic asthma. CONCLUSION: Using interactive small group workshops to disseminate locally adapted guidelines was associated with improvement in GP's knowledge and confidence to manage asthma, but did not change GP's self-reported provision of written action plans.

Group OSCE (GOSCE) as a formative clinical assessment tool for pre-clerkship medical students at the University of Sharjah.

OBJECTIVES: Continuous formative assessment with appropriate feedback is the pillar of effective clinical teaching and learning. Group Objective Structured Clinical Examination (GOSCE) has been reported as a resource-effective method of formative assessment. The present study aims to describe the development and evaluation of GOSCE as a formative assessment for pre-clerkship medical students. METHODS: At the University of Sharjah, GOSCE was introduced to medical students in Years 1, 2, and 3. The GOSCE was conducted as a formative assessment in which groups of 4-5 students were observed while they performed various clinical skills, followed by structured feedback from clinical tutors and peers. GOSCE was evaluated both quantitatively and qualitatively and appropriate statistical analysis was applied to evaluate their responses. RESULTS: A total of 232 students who attended the GOSCE responded to the questionnaires. Most of the students and clinical tutors preferred formative GOSCE over individual feedback. Both students and clinical tutors valued the experience as it helped students to identify gaps and to share knowledge and skills among group members. CONCLUSION: This study found that formative GOSCE provided a valuable and feasible educational opportunity for students to receive feedback about their clinical skills.

Stress, culture and 'home': social context in Turkish and Arabic-speaking Australians' views of diabetes prevention.

ISSUE ADDRESSED: A high prevalence of type 2 diabetes and diabetes risk factors exists among Middle East-born communities, largely attributed to modifiable lifestyle factors. Understanding the interplay between individual behaviour and societal and environmental factors would assist in planning interventions to reduce diabetes prevalence in these groups. This study explores the knowledge, attitudes and perceptions of diabetes and its prevention in Turkish and Arabic-speaking communities in metropolitan Melbourne, Victoria, Australia. METHOD: Turkish and Arabic-speaking people with risk factors of developing diabetes were invited to attend focus groups. Discussions were audiotaped and transcribed with the assistance of interpreters and then analysed by two researchers independently to ensure validity. Common themes were drawn upon and reported. RESULTS: Fifty-two people (41 females and 11 males, mean age=58.8 years) participated in five focus groups. Understanding of diabetes and potential for reducing risk of diabetes is closely linked to social context. Individual behaviours around diet and exercise, while partly influenced by cultural factors, are framed by concerns about public safety and food quality, which are themselves closely linked to experiences of social exclusion and marginalisation. CONCLUSION: These factors limit potential for individual behaviour change and are implicated in the way chronic stress acts as a common pathway through which individual health comes to embody social context.

Creating a Framework for Medical Professionalism: An Initial Consensus Statement From an Arab Nation.

Background Medical professionalism has received increased worldwide attention, yet there is limited information on the applicability and utility of established Western professionalism frameworks in non-Western nations. Objective We developed a locally derived consensus definition of medical professionalism for the United Arab Emirates (UAE), which reflects the cultural and social constructs of the UAE and the Middle East. Methods We used a purposive sample of 14 physicians working in the UAE as clinical and education leaders. This expert panel used qualitative methods, including the world café, nominal group technique, the Delphi method, and an interpretive thematic analysis to develop the consensus statement. Results The expert panel defined 9 attributes of medical professionalism. There was considerable overlap with accepted Western definitions, along with important differences in 3 aspects: (1) the primacy of social justice and societal rights; (2) the role of the physician's personal faith and spirituality in guiding professional practices; and (3) societal expectations for professional attributes of physicians that extend beyond the practice of medicine. Conclusions Professionalism is a social construct influenced by cultural and religious contexts. It is imperative that definitions of professionalism used in the education of physicians in training and in the assessment of practicing physicians be formulated locally and encompass specific competencies relevant to the local, social, and cultural context for medical practice. Our goal was to develop a secular consensus statement that encompasses culture and values relevant to professionalism for the UAE and the Arab region.

Spirometry and regular follow-up do not improve quality of life in children or adolescents with asthma: Cluster randomized controlled trials.

RATIONALE: To determine whether spirometry and regular medical review improved quality of life or other outcomes in children and adolescents with asthma. METHODS: We conducted two cluster randomized controlled trials. We recruited 238 asthma patients aged between 7 and 17 years from 56 general practices in South Eastern Australia. Participants were randomized to receive an intervention that included spirometry or usual care. The main outcome measure was asthma related quality of life. RESULTS: Baseline characteristics were well matched between the intervention and control groups. Neither trial found any difference in asthma related quality of life between groups. However because of measurement properties, a formal meta-analysis could not be performed. Nor were there any significant effects of the intervention upon asthma attacks, limitation to usual activities, nocturnal cough, bother during physical activity, worry about asthma, or written asthma action plans. CONCLUSIONS: The findings do not support more widespread use of spirometry for the management of childhood asthma in general practice, unless it is integrated into a complete management model.

Do spirometry and regular follow-up improve health outcomes in general practice patients with asthma or COPD? A cluster randomised controlled trial.

OBJECTIVE: To determine whether spirometry with regular medical review improves the quality of life or other health outcomes among patients with asthma or chronic obstructive pulmonary disease (COPD) managed in general practice. DESIGN, SETTING AND PARTICIPANTS: Cluster randomised controlled trial conducted in 31 general practices in Melbourne during 2007-2008. Practices recruited 305 adult patients who had been prescribed inhaled medication in the preceding 6 months. INTERVENTION: Practices were randomly assigned to one of three groups: Group A patients received 3-monthly spirometry performed by a respiratory scientist with results returned to the practice and regular medical review; Group B patients received spirometry only before and after the trial; and Group C patients received usual care. MAIN OUTCOME MEASURES: Quality of life, assessed with the 36-item Short Form (SF-36) Australian (English) Version 2 questionnaire at baseline and 3, 6, 9 and 12 months. Secondary outcomes were assessed with the European Community Respiratory Health Survey at baseline and 12 months. RESULTS: The trial was completed by 253 participants: 79 in Group A, 104 in Group B, and 70 in Group C. Median age was 58 years (range, 18-70 years), and 167 participants (66%) were women. There were no significant changes in SF-36 Physical and Mental Component Summary scores from baseline to 12 months, or significant differences between groups on either scale or any subscale of the SF-36. There were also no significant differences in respiratory symptoms, asthma attacks, written asthma action plans, days lost from usual activities or health care utilisation. CONCLUSION: Three-monthly spirometry and regular medical reviews by general practitioners are not associated with any significant improvement in quality of life or other health outcomes for patients with asthma and/or COPD. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12606000378527.