Dynamics of colorectal cancer screening in low and middle-income countries: A modeling analysis from Thailand.

BACKGROUND: Low and middle-income countries face constraints for early colorectal cancer (CRC) detection, including restricted access to care and low colonoscopy capacity. Considering these constraints, we studied strategies for increasing access to early CRC detection and reducing CRC progression and mortality rates in Thailand. METHODS: We developed a system dynamics model to simulate CRC death and progression trends. We analyzed the impacts of increased access to screening via fecal immunochemical test and colonoscopy, improving access to CRC diagnosis among symptomatic individuals, and their combination. RESULTS: Projecting the status quo (2023-2032), deaths per 100K people increase from 87.5 to 115.4, and CRC progressions per 100K people rise from 131.8 to 159.8. In 2032, improved screening access prevents 2.5 CRC deaths and 2.5 progressions per 100K people, with cumulative prevented 7K deaths and 9K progressions, respectively. Improved symptom evaluation access prevents 7.5 CRC deaths per 100K with no effect on progression, totaling 35K saved lives. A combined approach prevents 9.3 deaths and 1.8 progressions per 100K, or 41K and 7K cumulatively. The combined strategy prevents most deaths; however, there is a tradeoff: It prevents fewer CRC progressions than screening access improvement. Increasing the current annual colonoscopy capacity (200K) to sufficient capacity (681K), the combined strategy achieves the best results, preventing 15.0 CRC deaths and 10.3 CRC progressions per 100K people, or 54K and 30K cumulatively. CONCLUSION: Until colonoscopy capacity increases, enhanced screening and symptom evaluation are needed simultaneously to curb CRC deaths, albeit not the best strategy for CRC progression prevention.

Improving surgical skills with feedback: directly-observed versus video-recorded practice.

OBJECTIVE: This study aimed to compare two methods of feedback: verbal face-to-face feedback after direct observation (F2F-feedback) versus electronic-written feedback after observation of recorded-VDO of student's performance (VDO-feedback), in terms of effectiveness in improving skill, effects on motivation and satisfaction. BACKGROUND: Medical schools are responsible for teaching and ensuring proficiency of basic surgical skills. Feedback is effective in developing psychomotor skills; by providing information of learner's current performance, how to improve, and enhancing motivation. MATERIALS AND METHOD: Fifty-eight medical students (3rd- 4th year) were trained to perform vertical mattress suture in small groups. Then, during 6-week period of self-directed practice, students were randomized into group1 VDO-feedback (male:female = 21:8) and group 2 F2F-feedback (male:female = 20:9). Feedbacks were provided once every 2 weeks (Week2, Week4). End-of-rotation OSCE was at Week6, and retention tested was at Week8. Performance checklist (Cronbach's Alpha 0.72) was used to assess skill at 4 timepoints; pre- and post- small group learning, OSCE, and retention phase. Questionnaire was used to assess motivation, learning strategies and satisfaction (Cronbach's Alpha 0.83). RESULT: After in-class learning, further significant improvement of skills could be gained by both F2F- and VDO- feedbacks (p < 0.0001). Both could similarly retain skill for at least 4 weeks later without additional practice. Self-efficacy, test anxiety, and cognitive strategies scores were significantly increased in both groups (p < 0.05). Extrinsic motivation was increased in VDO-feedback group. No difference in satisfaction between groups was observed. DISCUSSION AND CONCLUSION: VDO-feedback could be alternative to F2F-feedbacks for basic surgical skill training when limitation for simultaneous meeting of teacher and students occurs. TRIAL REGISTRATION: This study has been registered to Thai Clinical Trial Registry (WHO International Clinical Trial Registry Platform) on 11/07/2023 (TCTR20230711005).

Factors influencing preoperative chest radiography request for elective endoscopic procedures among medical personnel.

BACKGROUND: Chest radiography is not routinely recommended before elective endoscopies. A high incidence of perioperative chest radiography requests was observed at our institution. This study aims to investigate factors influencing preoperative chest radiography request for patients undergoing elective gastrointestinal (GI) endoscopies. METHODS: This cross-sectional clinical study recruited 264 participants from different medical specialties who were responsible for preoperative endoscopic chest x-ray (CXR) ordering including anesthesiologists, surgeons and gastroenterologists. They completed questionnaires exploring their general knowledge and attitudes about preoperative chest radiography. Demographic characteristic of the participants affecting the knowledge on preoperative chest radiography was determined. A Structural Equation Model (SEM) was constructed from validated conceptual framework to find causal relationships between hypothesized factors and intention for preoperative endoscopic chest radiography request. Statistical analyses were performed using the SPSS software version 18.0 and Analysis of Moment Structures (AMOS) version 18.0. RESULTS: The questionnaire response rate was 53.79%. Baseline general knowledge on preoperative chest radiography of the participants was comparable. The SEM results showed unsupported relationship between hypothesized factors and the intention for preprocedural GI endoscopic CXR request (p < 0.1). CONCLUSIONS: General knowledge of medical personnel on tuberculosis needs improvement. To rectify the unnecessary chest radiography request before elective GI endoscopic procedures, awareness of the patients' health conditions, adherence to the hospital's policy and realizing of possible patient-related mishaps are not the determinants for preprocedural endoscopic chest radiography request. Future works are required to explore other alternative factors involved for reducing chest radiography requests which are not indicated.

Evaluating the effectiveness of rating instruments for a communication skills assessment of medical residents.

The investigators used evidence based on response processes to evaluate and improve the validity of scores on the Patient-Centered Communication and Interpersonal Skills (CIS) Scale for the assessment of residents' communication competence. The investigators retrospectively analyzed the communication skills ratings of 68 residents at the University of Illinois at Chicago (UIC). Each resident encountered six standardized patients (SPs) portraying six cases. SPs rated the performance of each resident using the CIS Scale--an 18-item rating instrument asking for level of agreement on a 5-category scale. A many-faceted Rasch measurement model was used to determine how effectively each item and scale on the rating instrument performed. The analyses revealed that items were too easy for the residents. The SPs underutilized the lowest rating category, making the scale function as a 4-category rating scale. Some SPs were inconsistent when assigning ratings in the middle categories. The investigators modified the rating instrument based on the findings, creating the Revised UIC Communication and Interpersonal Skills (RUCIS) Scale--a 13-item rating instrument that employs a 4-category behaviorally anchored rating scale for each item. The investigators implemented the RUCIS Scale in a subsequent communication skills OSCE for 85 residents. The analyses revealed that the RUCIS Scale functioned more effectively than the CIS Scale in several respects (e.g., a more uniform distribution of ratings across categories, and better fit of the items to the measurement model). However, SPs still rarely assigned ratings in the lowest rating category of each scale.

Selecting a measurement model for the analysis of the National Institutes of Health Stroke Scale.

To select the most appropriate model for the analysis of data from the National Institutes of Health Stroke Scale (NIHSS), the graded-response, Rasch partial credit, and generalized partial credit models were used to analyze NIH stroke data of 1,191 acute ischemic stroke patients. Based on Akaike's Information Criterion (AIC) and Bayesian Information Criterion (BIC), the generalized partial credit model has the most generalizable parameters. Items on the NIHSS have different discriminating powers. The generalized partial credit model, which allows varying slopes of item response functions, is the most appropriate model for the analysis of the NIHSS.

Quality control of an OSCE using generalizability theory and many-faceted Rasch measurement.

An Objective Structured Clinical Examination (OSCE) is an effective method for evaluating competencies. However, scores obtained from an OSCE are vulnerable to many potential measurement errors that cases, items, or standardized patients (SPs) can introduce. Monitoring these sources of errors is an important quality control mechanism to ensure valid interpretations of the scores. We describe how one can use generalizability theory (GT) and many-faceted Rasch measurement (MFRM) approaches in quality control monitoring of an OSCE. We examined the communication skills OSCE of 79 residents from one Midwestern university in the United States. Each resident performed six communication tasks with SPs, who rated the performance of each resident using 18 5-category rating scale items. We analyzed their ratings with generalizability and MFRM studies. The generalizability study revealed that the largest source of error variance besides the residual error variance was SPs/cases. The MFRM study identified specific SPs/cases and items that introduced measurement errors and suggested the nature of the errors. SPs/cases were significantly different in their levels of severity/difficulty. Two SPs gave inconsistent ratings, which suggested problems related to the ways they portrayed the case, their understanding of the rating scale, and/or the case content. SPs interpreted two of the items inconsistently, and the rating scales for two items did not function as 5-category scales. We concluded that generalizability and MFRM analyses provided useful complementary information for monitoring and improving the quality of an OSCE.

Rater errors in a clinical skills assessment of medical students.

The authors used a many-faceted Rasch measurement model to analyze rating data from a clinical skills assessment of 173 fourth-year medical students to investigate four types of rater errors: leniency, inconsistency, the halo effect, and restriction of range. Students performed six clinical tasks with 6 standardized patients (SPs) selected from a pool of 17 SPs. SPs rated the performance of each student in six skills: history taking, physical examination, interpersonal skills, communication technique, counseling skills, and physical examination etiquette. SPs showed statistically significant differences in their rating severity, indicating rater leniency error. Four SPs exhibited rating inconsistency. Four SPs restricted their ratings in high categories. Only 1 SP exhibited a halo effect. Administrators of objective structured clinical examinations should be vigilant for various types of rater errors and attempt to reduce or eliminate those errors to improve the validity of inferences based on objective structured clinical examination scores.

Predicting academic achievement in the medical school with high school grades.

OBJECTIVE: The present study investigated whether high school grades can predict medical school grades after controlling for the effects of demographics and entrance examination scores. MATERIAL AND METHOD: The authors used hierarchical multiple regression analyses to predict medical school grades of 223 medical students in the 1997 entering class of the Faculty of Medicine Siriraj Hospital, Thailand, using age, gender, entrance examination scores, and high school grades as predictors. RESULTS: After controlling for demographics and entrance examination scores, high school grades provided significant prediction only for premedical grades. The type of entrance examination that students took and the type of high school curriculum that the students studied were significant predictors of medical school grades in every level. CONCLUSION: Measures of cognitive abilities in academic content were good in predicting short-term academic achievement. Long-term academic achievement in the medical school could be better predicted from academic orientation, commitment to the medical study, and demographic traits.

Moral education in medical schools.

The present report summarizes challenges in teaching medical ethics, defines its goals, describes theoretical frameworks for moral education, and reviews strategies for teaching medical ethics to serve as guidelines in developing medical ethics instruction. Medical teachers should clarify the instructional goals in cognitive, attitudinal, and behavioral domains. The cognitive developmental and behavior-analytic theories called for ethical instruction using a series of discussions based on real-life ethical dilemmas while pointing out all the basic rules related to medical practice. Ethical courses for medical students should be student-centered, problem-based, and integrative. Ethical instruction should be systematically taught to every student, but additional elective courses could also be used. Moral education for residents should be more focused to issues specific to their specialties. Medical researchers need both formal ethical training and informal teaching, and role modeling. Finally, experienced staff could use small group discussions of shared ethical problems to maintain their ethical knowledge and skills.

Outcomes of local excision for early rectal cancer: a 6-year experience from the largest university hospital in Thailand.

BACKGROUND: This study aimed to determine clinical outcomes of local excision for early rectal cancer from a University Hospital in Thailand. MATERIALS AND METHODS: We performed a retrospective review of 22 consecutive patients undergoing local excision for early rectal cancer (clinical and radiological T1/T2) from 2005-2010 at the Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok. Data were collected from patients' medical records, including demographic and clinical characteristics, pathological report and surgical outcomes. RESULTS: This study included 10 males and 12 females, with average age of 68 years. Nineteen patients (86%) underwent transanal excision and the others had trans-sacral excision. Median operative time was 45 minutes. Postoperative complications occurred in 2 patients (9%); 1 fecal fistula and 1 wound infection following trans-sacral excision. There was no 30-day postoperative mortality. Median hospital stay was 5 days. Pathological reports revealed T1 lesion in 12 cases (55%), T2 lesion in 8 cases (36%) and T3 lesion in 2 cases (9%). Eight patients received additional treatment; one re-do transanal excision, two proctectomies, and five adjuvant chemoradiation. During the median follow-up period of 25 months, local recurrence was detected in 4 patients (18%); two cases of T2 lesions with close or positive margins, and two cases of T3 lesions. Three patients with local recurrence underwent salvage abdominoperineal resection. No local recurrence was found in T1/T2 lesions with free surgical margins. CONCLUSIONS: Local excision is a feasible and acceptable alternative to radical resection only in early rectal cancer with free resection margins and favorable histopathology.

Surgery for gastrointestinal malignant melanoma: experience from surgical training center.

AIM: To characterize clinical features, surgery, outcome, and survival of malignant melanoma (MM) of the gastrointestinal (GI) tract in a surgical training center in Bangkok, Thailand. METHODS: A retrospective review was performed for all patients with MM of the GI tract treated at our institution between 1997 and 2007. RESULTS: Fourteen patients had GI involvement either in a metastatic form or as a primary melanoma. Thirteen patients with sufficient data were reviewed. The median age of the patients was 66 years (range: 32-87 years). Ten patients were female and three were male. Seven patients had primary melanomas of the anal canal, stomach and the sigmoid colon (5, 1 and 1 cases, respectively). Seven patients underwent curative resections: three abdominoperineal resections, two wide local excisions, one total gastrectomy and one sigmoidectomy. Six patients had distant metastatic lesions at the time of diagnosis, which made curative resection an inappropriate choice. Patients who underwent curative resection exhibited a longer mean survival time (29.7 mo, range: 10-96 mo) than did patients in the palliative group (4.8 mo, P = 0.0006). CONCLUSION: GI MM had an unfavorable prognosis, except in patients who underwent curative resection (53.8% of cases), who had a mean survival of 29.7 mo.

Instruction and assessment of professionalism for surgery residents.

Surgical professionalism is one of the core competencies for surgery residents. It focuses on professional responsibilities to patients and society. This report summarizes current literature on surgical professionalism to help surgical residency program directors organize appropriate instruction and assessment methods for their residents. The instructional design should be based on 14 key concepts of surgical professionalism outlined by the American College of Surgeons. The professionalism curriculum should be a mixture between faculty-identified concepts and resident input of context that those concepts apply. Surgical faculty should start the instruction with a lecture, which later leads to problem solving of cases related to surgical professionalism. Surgical faculty should integrate professionalism instruction in everyday practice in all clinical settings, using both structured and apprenticeship approaches. A comprehensive assessment of professionalism requires both a maximal and a typical performance assessment. The test of maximal performance in an Objective Structured Clinical Examination (OSCE) format is suggested for the assessment of professionalism in situations that do not occur often. The test of typical performance can be achieved with ratings from faculty, peers, nurses, and patients to evaluate professionalism competence in regular clinical services.

A clinical nutrition course to improve pharmacy students' skills and confidence in counseling patients.

OBJECTIVE: To create, implement, and evaluate a PharmD course on primary care nutrition. DESIGN: A 2-credit hour elective course was offered to second- and third-year pharmacy students. It was informed by the Socratic method using a minimum number of formal lecture presentations and featured problem-based learning exercises, case-based scenarios, and scientific literature to fuel informed debate. A single group posttest design with a retrospective pretest was used to assess students' self-efficacy. ASSESSMENT: There was a significant overall improvement in students' self-efficacy in their ability to practice primary care nutrition. CONCLUSION: Completion of a nutrition course improved students' confidence in providing primary care nutrition and empowered them to speak more comfortably about the role of nutrition in the prevention of chronic diseases.

Measurement properties of the National Institutes of Health Stroke Scale for people with right- and left-hemisphere lesions: further analysis of the clomethiazole for acute stroke study-ischemic (class-I) trial.

OBJECTIVE: To assess the psychometric properties of the National Institutes of Health Stroke Scale (NIHSS) in people with either left or right acute hemisphere stroke for the purpose of improving the scale's sensitivity in detecting neurologic impairment. DESIGN: Secondary analysis of data from the Clomethiazole for Acute Stroke Study-Ischemic using the Rasch partial credit model. We evaluated the data's measurement properties using item-total correlations, Rasch item fit statistics, principle component analysis of standardized person and item residuals, differential item functioning, separation reliability, and the separation ratio. SETTING: Original data were collected in academic and community hospitals as part of a clinical trial. PARTICIPANTS: People with acute ischemic stroke who were seen within 12 hours of onset: 380 people with left-hemisphere stroke and 347 with right-hemisphere stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The NIHSS. RESULTS: Items of the NIHSS function differently in the right- and left-hemisphere lesion groups. We constructed for each group separate linear scales consisting of a subset of items of the NIHSS to improve its measurement properties. CONCLUSIONS: Our findings provide initial support for the use of individual, targeted scales for measurement of impairment after ischemic stroke. Low person separation reliability may be a consequence of the sample, which included only people with large ischemic cortical strokes.