Exploring clinical teachers' beliefs about teaching in a newly established medical school in Southern Switzerland.

Academic social contexts and educational beliefs may influence teaching practices and teaching intentions. Insight into such beliefs represents an important source of information for medical schools to improve the quality of teaching and to guide content of faculty development programs. The aim of this study was to explore beliefs about teaching among prospective clinical teachers at a newly established medical school in Southern Switzerland and to estimate the relationship between these beliefs and intention to commit to teaching in the newly established medical curriculum using Fishbein's integrative model of behaviour prediction. We targeted a purposive sample of physicians working in hospital departments potentially involved in the clinical immersion of medical students enrolled in the program. We designed a cross-sectional quantitative study using an online questionnaire. The questionnaire included both items developed by the authors and items belonging to a previously validated questionnaire. Participants showed a high intention to commit to teaching in the newly established curriculum. We found that self-efficacy beliefs and two sets of behavioural beliefs, namely perceived importance and expectations, had a positive correlation with the intention to commit. On the other hand, we pointed out a number of normative beliefs that in the long run could hinder the maintenance of this commitment, which should be addressed both at the levels of both faculty development and institutional policy rules. Our study also highlights the importance of reinforcing teachers' perceived self-efficacy in providing clinical supervision, strengthening their perceived importance of the clinical supervision, and incentivising the commitment of teachers by ensuring they have protected time to devote to this activity.

Challenges in the transition from resident to attending physician in general internal medicine: a multicenter qualitative study.

BACKGROUND: The attending physician in general internal medicine (GIM) guarantees comprehensive care for persons with complex and/or multiple diseases. Attendings from other medical specialties often report that transitioning from resident to attending is burdensome and stressful. We set out to identify the specific challenges of newly appointed attendings in GIM and identify measures that help residents better prepare to meet these challenges. METHODS: We explored the perceptions of 35 residents, attendings, and department heads in GIM through focus group discussions and semi-structured interviews. We took a thematic approach to qualitatively analyze this data. RESULTS: Our analysis revealed four key challenges: 1) Embracing a holistic, patient centered perspective in a multidisciplinary environment; 2) Decision making under conditions of uncertainty; 3) Balancing the need for patient safety with the need to foster a learning environment for residents; and 4) Taking on a leader's role and orchestrating an interprofessional team of health care professionals. Newly appointed attendings required extensive practical experience to adapt to their new roles. Most attendings did not receive regular, structured, professional coaching during their transition, but those who did found it very helpful. CONCLUSIONS: Newly appointed attending physician in GIM face a number of critical challenges that are in part specific to the field of GIM. Further studies should investigate whether the availability of a mentor as well as conscious assignment of a series of increasingly complex tasks during residency by clinical supervisors will facilitate the transition from resident to attending.

[Central venous catheter, PICC-line or Midline†: which catheter for my patient?] / Voie centrale, PICC-line ou Midline†: quel cathéter pour quel patient†?

Midline long peripheral venous catheters are an interesting alternative to central venous catheters and PICC-lines when the placement of a peripheral venous catheter is impossible or when the patient requires prolonged intravenous treatment. Midline catheters can be inserted at the patient's bedside and require no radiological verification after insertion. They can be kept in place for up to 14 days and allow for repeated blood sampling. The mechanical, infectious, or thrombotic complications and safety profile do not differ from other venous catheters, notably PICC-line.

Lorsque la pose d'un cathéter veineux périphérique est impossible ou que le patient nécessite un traitement intraveineux prolongé, les cathéters veineux périphériques longs, de type Midline, représentent une alternative intéressante aux cathéters veineux centraux et PICC-line (Peripherally Inserted Central Catheters). Les Midlines peuvent être mis en place au lit du patient, sans nécessiter un contrôle radiologique après la pose. Ils peuvent rester en place jusqu'à 14 jours et permettent d'effectuer des prélèvements sanguins répétés. Les complications mécaniques, infectieuses ou thrombotiques, et le profil de sécurité ne diffèrent pas des autres cathéters veineux, notamment des PICC-lines.

[Teaching and learning during attending rounds in internal medicine: an anthropological study]. / Enseigner et apprendre lors des grandes visites en médecine interne hospitalière : Une étude anthropologique.

This anthropological research aims to highlight the educational approaches in action during attending rounds. The goal is to understand how specific learning domains, professional socialization and learning environments are influenced by the different ways of conducting attending rounds. Two formats of rounds were noted: the IN format, when the patient case is presented in the patient room, and the OUT format. Six educational approaches were identified. The attending round format has an impact on the approaches used. The latter contribute to the development, to varying degrees, of knowledge, skills and attitudes. Attending rounds remain a space for "top-down" transmission and supervision, even though some approaches involve learner initiatives and peer group logic.

Notre recherche anthropologique vise à mettre en lumière les approches pédagogiques à l'œuvre durant les grandes visites. Comment les domaines d'apprentissages visés, la socialisation professionnelle et l'environnement d'apprentissage sont-ils influencés par les différentes manières de les conduire ? Deux formes de visites sont retrouvées : la forme IN (le cas est présenté au lit du patient) et la forme OUT. Six approches pédagogiques ont été identifiées. La forme de grande visite influence les approches pédagogiques mobilisées. Celles-ci contribuent à développer, à des degrés variables, des savoirs, savoir-faire et savoir-être. Les grandes visites restent un espace de transmission « top-down ¼ et de surveillance, même si certaines approches encouragent les initiatives des apprenants ainsi que les logiques de groupes de pairs.

[Roles and challenges of Point-of-Care Ultrasonography in internal medicine]. / Rôles et défis de l'ultrasonographie ciblée en médecine interne hospitalière.

Point-of-Care Ultrasonography (POCUS) is an emerging important diagnostic tool in internal medicine wards. The concept is to focus on specific or binary questions to rule in disease and has a proven additional benefit for procedural guidance in terms of patients' safety. Its advantages lie in its rapid and non-invasive use at the patient's bedside. It does not replace the traditional diagnostic procedures or specialists' investigations. Since medical decisions can be guided by ultrasounds results, it's important to remember that the diagnostic performance is largely operator dependent. Implementation of POCUS in internal medicine wards is still challenging regarding the small number of ultrasound experts to provide education programs and the lack of well-established learning objectives and training programs.

L'ultrasonographie ciblée (POCUS) a gagné en importance dans la pratique hospitalière comme aide pour l'orientation diagnostique. Devenue incontournable pour la réalisation de procédures invasives de façon sécuritaire, ses atouts résident dans sa capacité de répondre rapidement, au lit du malade, de façon binaire (oui/non), à des questions spécifiques. Il reste important de se souvenir que son recours ne remplace pas les démarches diagnostiques traditionnelles, ni l'examen du spécialiste, et que la qualité d'un examen et des conclusions en découlant est hautement dépendante du niveau de formation et des compétences de l'utilisateur. L'implémentation sécuritaire du POCUS en médecine interne reste encore un défi au niveau de la formation des cliniciens, notamment en termes de cursus, encore non clairement défini, et du faible nombre de formateurs.

Improving the assessment of communication competencies in a national licensing OSCE: lessons learned from an experts' symposium.

BACKGROUND: As the communication competencies of physicians are crucial for providing optimal patient care, their assessment in the context of the high-stakes Objective Structured Clinical Examination (OSCE) is of paramount importance. Despite abundant literature on the topic, evidence-based recommendations for the assessment of communication competencies in high stakes OSCEs are scarce. As part of a national project to improve communication-competencies assessments in the Swiss licensing exam, we held a symposium with national and international experts to derive corresponding guidelines. METHODS: Experts were invited on account of their recognized expertise either in teaching or assessing communication competencies, or in conducting national high-stakes OSCEs. They were asked to propose concrete solutions related to four potential areas for improvement: the station design, the rating tool, the raters' training, and the role of standardized patients. Data gene.rated in the symposium was available for analysis and consisted of video recordings of plenary sessions, of the written summaries of group work, and the cards with participants' personal take-home messages. Data were analyzed using a thematic analysis approach. RESULTS: Nine major suggestions for improving communication-competencies assessments emerged from the analysis and were classified into four categories, namely, the roles of the OSCE scenarios, rating tool, raters' training, and simulated patients. CONCLUSION: In the absence of established evidence-based guidelines, an experts' symposium facilitated the identification of nine practical suggestions for improving the assessment of communication competencies in the context of high-stakes OSCEs. Further research is needed to test effectiveness of the suggestions and how they contribute to improvements in the quality of high-stakes communication-competencies assessment.

[PROFILES: typical portrait of the future Swiss doctors]. / PROFILES: portrait-type de nos futurs médecins !

In each professional practice, a greater or lesser part of the activity is devoted to teaching. Indeed, the transmission of the medical knowledge is an essential objective for the training of students and residents, but also an opportunity to adapt one's own practices to the current context, since fast changes are not necessarily easy to follow and assimilate. If the relationship with Medical school is rather straightforward in the university hospitals, it is not always the same for those who are more distant, but whose participation in teaching is desired, and clearly growing. In this way, it is therefore crucial that everyone is informed about recent changes to the undergraduated learning objectives (PROFILES) and the resulting needs for educational reforms for all Medical schools in Switzerland.

Dans chaque pratique professionnelle, une part plus ou moins grande de l'activité est dévolue à l'enseignement. En effet, la transmission de l'art médical représente un objectif essentiel pour la formation des étudiant·e·s et des jeunes collègues, mais aussi une opportunité pour adapter ses pratiques au contexte actuel, car les changements, rapides, ne sont pas forcément faciles à assimiler. Si, dans les hôpitaux universitaires, le contact avec les Facultés de médecine est plutôt aisé, il n'en va pas toujours de même pour ceux qui en sont plus distants, mais dont la participation à l'enseignement est souhaitée et croissante. En ce sens, il apparaît crucial que tou·te·s soient informé·e·s sur les modifications récentes des objectifs d'apprentissage prégradué (PROFILES) et sur les réformes qui en découlent pour les Facultés de médecine en Suisse.

[Medical students at the bedside of COVID-19 patients†: motivations and challenges]. / Étudiant·e·s en médecine engagé·e·s au chevet des patient·e·s hospitalisé·e·s pour COVID-19 - Motivations et enjeux.

The SARS-CoV-2 pandemic is putting our healthcare system under exceptional pressure, given the number of affected patients. In a context of limited human healthcare resources, senior medical students represent a valuable workforce that can quickly be mobilized for patient care. This is the approach followed in Switzerland and other countries, in several outpatient structures or inpatient services, including the Department of Internal Medicine, of the Lausanne University Hospital (CHUV). In this article, we first give the floor to students who responded to our call. We conclude with important considerations in terms of students' clinical supervision. It is reminded that the involvement of students in the care of COVID-19 patients should only occur on a vo luntary basis.

La pandémie de COVID-19 met notre système de santé sous une pression exceptionnelle, au vu du nombre de patient·e·s atteint·e·s. Dans un contexte de ressources humaines médico-soignantes limitées, les étudiant·e·s en médecine avancé·e·s dans leur cursus représentent un renfort très précieux, rapidement mobilisable auprès des patient·e·s. C'est la démarche suivie en Suisse et ailleurs dans le monde par diverses structures ambulatoires ou services hospitaliers, dont le Service de médecine interne du Centre hospitalier universitaire vaudois (CHUV). Dans cet article, nous donnons tout d'abord la parole aux étudiant·e·s qui ont répondu à notre appel. Nous terminons par des considérations importantes quant à l'accueil et l'accompagnement de ces étudiant·e·s. Il est rappelé que l'engagement d'étudiant·e·s auprès de patient·e·s souffrant de COVID-19 devrait se faire sur une base volontaire uniquement.

[Organizational Impacts and Clinical Challenges of the COVID-19 Pandemic on a Swiss Tertiary Internal Medicine Department]. / Impacts organisationnels et défis cliniques de la pandémie COVID-19 pour un service hospitalier de médecine interne universitaire.

The rapid progression of COVID-19 is an organizational challenge for all hospitals. To secure the patient overflow, the Department internal medicine of the University Hospital of Lausanne increased nurse and medical workforces as well as bed capacity by 65 %, with extraordinary help from other departments. The implemented crisis management stood upon three pillars : a crisis management team, steering documents and internal communication. In this new form, the Department had already taken care of 442 COVID-19 admissions by April 16, 2020. Alongside organizational challenges, clinical issues such as rapid respiratory distress, clinical suspicions with negative PCR and treatment uncertainties in the absence of sufficient evidence were overcome. Despite the peak of the pandemic appearing to have passed, the next phase could be just as complicated.

La progression rapide du COVID-19 constitue un défi organisationnel pour tous les hôpitaux. Pour anticiper un afflux important de patients, le service de médecine interne du CHUV a ainsi augmenté ses forces de travail médico-soignantes et son nombre de lits de 65 % avec un soutien extraordinaire de toute l'institution. Pour opérer ces changements majeurs, l'organisation de crise mise en place s'est appuyée sur trois piliers : une cellule de conduite, des documents de pilotage et une communication interne. Sous cette nouvelle forme, le service a pris en charge 442 hospitalisations COVID-19 jusqu'au 16 avril 2020. Si les enjeux organisationnels ont été majeurs, la gestion des situations complexes, comme les manifestations respiratoires et les multiples incertitudes cliniques diagnostiques et thérapeutiques, ont été également une gageure. Le pic de la pandémie semble passé, mais la prochaine phase pourrait constituer un nouveau défi organisationnel.

Formation and emission of large furans and oxygenated hydrocarbons from flames.

Many oxygenated hydrocarbon species formed during combustion, such as furans, are highly toxic and detrimental to human health and the environment. These species may also increase the hygroscopicity of soot and strongly influence the effects of soot on regional and global climate. However, large furans and associated oxygenated species have not previously been observed in flames, and their formation mechanism and interplay with polycyclic aromatic hydrocarbons (PAHs) are poorly understood. We report on a synergistic computational and experimental effort that elucidates the formation of oxygen-embedded compounds, such as furans and other oxygenated hydrocarbons, during the combustion of hydrocarbon fuels. We used ab initio and probabilistic computational techniques to identify low-barrier reaction mechanisms for the formation of large furans and other oxygenated hydrocarbons. We used vacuum-UV photoionization aerosol mass spectrometry and X-ray photoelectron spectroscopy to confirm these predictions. We show that furans are produced in the high-temperature regions of hydrocarbon flames, where they remarkably survive and become the main functional group of oxygenates that incorporate into incipient soot. In controlled flame studies, we discovered ∼100 oxygenated species previously unaccounted for. We found that large alcohols and enols act as precursors to furans, leading to incorporation of oxygen into the carbon skeletons of PAHs. Our results depart dramatically from the crude chemistry of carbon- and oxygen-containing molecules previously considered in hydrocarbon formation and oxidation models and spearhead the emerging understanding of the oxidation chemistry that is critical, for example, to control emissions of toxic and carcinogenic combustion by-products, which also greatly affect global warming.

Characterization of selective solar absorber under high vacuum.

Total absorption and emission coefficients of selective solar absorbers are measured under high vacuum conditions from room temperature up to stagnation temperature. The sample under investigation is illuminated under vacuum @1000W/m2 and the sample temperature is recorded during heat up, equilibrium and cool down. During stagnation, the absorber temperature exceeds 300°C without concentration. Data analysis allows evaluating the solar absorptance and thermal emittance at different temperatures. These in turn are useful to predict evacuated solar panel performances at operating conditions.

[Importance of handoffs for patient safety]. / Sécurité des patients : importance des transmissions médicales.

Handoffs are defined as the transfer of mission specific information and care authority from one healthcare professional to another. Handoffs may create gaps that are especially vulnerable to errors and may have an impact on patient safety. Conceptualising handoffs that are safe gains in importance in medicine with the growing clinical complexity, the reduction of working hours, and a great amount of care fragmentation. Different strategies on the handoff procedure have been identified to improve patient safety. An institutional approach with adaptations to the specific characteristics of each medical discipline is necessary.

Les transmissions médicales sont à risque de générer des discontinuités qui peuvent entraver la sécurité des patients. Avec la complexité croissante des situations cliniques, la réduction des heures de travail ainsi que la fragmentation des prises en charge, la conceptualisation de transmissions médicales sûres a gagné en importance dans le quotidien clinique. De nombreux modèles qui visent l'amélioration des transmissions médicales ont étés étudiés et se sont avérés efficaces pour augmenter la sécurité des patients. L'intégration d'un modèle de transmissions sûres nécessite un changement dans la culture institutionnelle ainsi qu'une approche adaptée aux spécificités de chaque discipline.

Accuracy of in-patients ankle-brachial index measurement by medical students.

BACKGROUND: Ankle brachial index (ABI) is a first line non-invasive screening tool for peripheral arterial disease (PAD) in at risk populations. The need to extend ABI use in large population screening has urged its use by professionals other than vascular physicians. As advocated by the American Heart Association, ABI teaching is part of medical curriculum in several countries. We determine accuracy in ABI measurement by trained medical students compared with an experienced angiologist. METHODS: Twelve 6th year medical students underwent 9 days of training at Lausanne University Hospital. Students and an experienced angiologist, blinded to students' results, screened consecutive hospitalised patients aged ≥ 65 or ≥ 50 with at least one cardiovascular risk factor during a 6-week period. RESULTS: A total of 249 patients were screened of whom 59 (23.7%) met the inclusion criteria. Median age was 80, 45.8% were women, and 6.8% were symptomatic. In total, 116 ABIs were available for analysis. Agreement between students and angiologist was moderate with a k-value of 0.498 (95% confidence interval: 0.389-0.606). Overall accuracy and precision of PAD screening performed by students showed sensitivity of 73.2% and specificity of 88.0%. Positive and negative predictive values were 76.9% and 85.7%, respectively; positive and negative likelihood ratios were 6.3 and 3, respectively. CONCLUSIONS: A nine day training program on ABI measurement is not sufficient for inexperienced medical students to achieve an acceptable diagnostic accuracy in detecting PAD in at risk populations.

[E-learning : an effective and necessary complement to the postgraduate training]. / E-learning : un complément efficace et nécessaire à la formation postgraduée.

The evolution of modern medicine largely influenced the development of new postgraduate training programs, which requirements are more engaging and constraining. Time dedicated to education more and more often comes into competition with the resident's clinical and administrative activities. In this context, E-learning could be an interesting solution, if used complementary to the classical training which does not further overload the clinical activity. By focusing on the recognition of clinical images, and interpretation of functional tests, we target some well known knowledge gaps of our trainees. Our program allows every participant to be exposed to some important, prototypical or rare situations, independent of the clinical exposure. The quality of our program is ensured by the collaboration with several specialty departments of our hospital.

L'évolution de la médecine est à l'origine du développement de programmes de formation postgraduée de plus en plus complexes et contraignants. Le contenu de cette formation est donc en pleine évolution et le temps dédié entre en compétition directe avec les activités cliniques et administratives du médecin assistant. Dans ce contexte, la formation en ligne (e-learning) peut être une solution complémentaire à la formation classique. Elle présente plusieurs avantages comme celui de pouvoir être effectuée au moment le plus propice, sans surcharger l'activité clinique et en réduisant les interruptions. Nous avons développé un programme de formation en ligne ciblant des thématiques qui nous semblent lacunaires chez nos médecins en formation. La qualité du programme est assurée par une fructueuse collaboration avec plusieurs services de spécialités de notre hôpital.

[The informatics: a remarkable tool for teaching general internal medicine]. / L'informatique: un outil remarquable pour l'enseignement de la médecine interne générale!

INTERMED training implies a three week course, integrated in the "primary care module" for medical students in the first master year at the school of medicine in Lausanne. INTERMED uses an innovative teaching method based on repetitive sequences of e-learning-based individual learning followed by collaborative learning activities in teams, named Team-based learning (TBL). The e-learning takes place in a web-based virtual learning environment using a series of interactive multimedia virtual patients. By using INTERMED students go through a complete medical encounter applying clinical reasoning and choosing the diagnostic and therapeutic approach. INTERMED offers an authentic experience in an engaging and safe environment where errors are allowed and without consequences.

A multi-method approach to drafting candidate entrustable professional activities for a general internal medicine residency programme.

INTRODUCTION: Entrustable professional activities (EPAs) are units of concrete daily clinical tasks that trainee physicians should be able to handle with increasing autonomy during their postgraduate training. EPAs are gaining international recognition as an essential component of competency-based medical training programmes. The process of developing EPAs for a nationwide training programme is complex and requires an in-depth understanding of EPAs as a concept and good knowledge of appropriate development processes. This article provides a detailed description of the methodology and results of a multi-step approach for developing a list of candidate EPAs for Switzerland's postgraduate training programme in general internal medicine (GIM). METHODS: We took a multi-step approach including a systematic review of international literature, four national focus groups, a national consensus process using a RAND appropriateness method, and a quality check of the selected candidate EPAs using EQual criteria. RESULTS: These steps generated a final list of 247 candidate EPAs in general internal medicine that were submitted for the national consensus process. After two rounds of rating, experts agreed on the appropriateness for general internal medicine postgraduate training of 225 candidate EPAs. Twenty-two were deemed inappropriate, and disagreement persisted only for two EPAs. DISCUSSION: This multi-step programme is one of the few describing in detail the process of developing a list of EPAs and providing evidence of validity at each step. The clinical breadth of our candidate EPAs, together with the detailed description of our methodology, could serve as a useful starting point from which medical education specialists or clinicians could develop or revise applicable lists of EPAs, particularly for postgraduate training programmes in either general internal medicine or family medicine.

Insight into magnetite's redox catalysis from observing surface morphology during oxidation.

We study how the (100) surface of magnetite undergoes oxidation by monitoring its morphology during exposure to oxygen at ~650 °C. Low-energy electron microscopy reveals that magnetite's surface steps advance continuously. This growth of Fe3O4 crystal occurs by the formation of bulk Fe vacancies. Using Raman spectroscopy, we identify the sinks for these vacancies, inclusions of α-Fe2O3 (hematite). Since the surface remains magnetite during oxidation, it continues to dissociate oxygen readily. At steady state, over one-quarter of impinging oxygen molecules undergo dissociative adsorption and eventual incorporation into magnetite. From the independence of growth rate on local step density, we deduce that the first step of oxidation, dissociative oxygen adsorption, occurs uniformly over magnetite's terraces, not preferentially at its surface steps. Since we directly observe new magnetite forming when it incorporates oxygen, we suggest that catalytic redox cycles on magnetite involve growing and etching crystal.

The influence of patient gender on medical students' care: Evaluation during an objective structured clinical examination.

OBJECTIVES: To assess whether men and women are evaluated and treated differently by medical students. METHODS: We evaluated patient care provided by 110 fifth-year medical students during an objective structured clinical examination (OSCE), using two clinical cases with standardized patients (SPs): generalized anxiety disorder (GAD) and ascending aortic dissection (AAD). Half of the students encountered male and half female SPs. Except for gender, the cases were identical. We compared diagnosis and treatment of male vs female SPs. RESULTS: Students diagnosed GAD more often in female SPs than in male SPs (diagnosis completed, partially completed, and not completed in 47%, 16% and 36% respectively vs. 22%, 20%, and 58% for male SPs, p = 0.02). The nature of symptoms was better described for male SPs. For AAD, the emergency was more frequently identified and the examination of femoral pulses better performed in female SPs. CONCLUSION: Medical students have a gender bias when evaluating patients with GAD and AAD. PRACTICE IMPLICATION: The observed gender bias in the evaluation of patients, likely leads to differences in treatment between male and female patients (i.e. under-recognition of anxiety in men). Medical schools should implement gender-sensitive medical education initiatives to improve inclusive patient care.