[The experience of the Faculty of Medicine at Sherbrooke University]. / L'expérience de la Faculté de Médecine de l'Université de Sherbrooke.

There is no Faculty of Medicine in the New Brunswick province of Canada. Thirty-three percent of its population is francophone. In an effort to improve the health status of this population, which is known to be inferior to that of its anglophone counterpart, and to fill the gap in terms of the lack of francophone physicians, a partnership was developed with the University of Sherbrooke's medical school. Therefore, a francophone medical training programme was established in New Brunswick, and as a community-based programme, it is oriented to serve the specific needs of this target group. This integrated and collaborative approach between the principal health partners has had a positive impact on improving the health status of the francophone population and on the francophone medical resources. It is a solid demonstration of the Towards Unity for Health approach and of the social responsibility of a medical school.

Initial experience of an objective structured clinical examination in evaluating urology residents.

OBJECTIVES: Objective Structured Clinical Examination (OSCE) is now generally considered as the new gold standard for evaluating clinical competence. The objective of this study was to assess the feasibility of OSCE in evaluating urology residents. MATERIAL AND METHODS: 20 urology residents rotated through a circuit of five standardized patient-based OSCE stations of 10 min duration. The selection of problems was based on educational objectives of urology residency programs. Written questionnaires based on Likert-type scales were used to measure OSCE feasibility. The mean score was arbitrarily used as a passing score. Student t test was only used to compare the performance between junior and senior residents. RESULTS: Senior residents performed globally better, but without significant differences (51.3+/-7.8 vs. 45.03+/-5.1, p>0.05). Senior resident scores regarding outpatient problems were significantly higher (p = 0.04), more senior residents reached the passing score (75 vs. 16% junior residents). All the participants agreed that the clinical situations were realistic and that the simulated patients were believable. Most participants agreed that the sampling of cases were representative of urology practice. CONCLUSIONS: This is the first reported OSCE applied to urology residency. The results of this pilot study support the feasibility of an OSCE in assessing the performance of urology residents. Our data raises questions regarding the training of outpatient consultation skills to residents. This experiment warrants further series to explore the study's psychometrics features.

[Teaching resources of a hospital Gynecology-Obstetrics service. Review of the literature and practical applications]. / Les ressources pédagogiques d'un service hospitalier de Gynécologie-Obstétrique. Revue de la littérature et applications pratiques.

OBJECTIVES: To summarize the methods encountered in a gynecological department for teaching medical students. STUDY: Review of the Medline literature underlying the benefits and disadvantages of each method using the issues of the modern theories of teaching. RESULTS: All the methods are helpful for learning, with different and complementary objectives. Students can constitute a set of skills using a teaching program containing clear objectives and evaluation on which the future medical practice will be based. CONCLUSION: Students have immediate benefits from an active clinical learning involving them and are prepared to the Continued Medical Education.

Association between licensing examination scores and resource use and quality of care in primary care practice.

CONTEXT: Clinical competence is a determinant of the quality of care delivered, and may be associated with use of health care resources by primary care physicians. Clinical competence is assumed to be assessed by licensing examinations, yet there is a paucity of information on whether scores achieved predict subsequent practice. OBJECTIVE: To determine if licensing examination scores were associated with selected aspects of quality of care and resource use in initial primary care practice. DESIGN: Prospective cohort study of recently licensed family physicians, followed up for the first 18 months of practice. SETTING: The Quebec health care system. PARTICIPANTS: A total of 614 family physicians who passed the licensing examination between 1991 and 1993 and entered fee-for-service practice in Quebec. MAIN OUTCOME MEASURES: All patients seen by physicians were identified by the universal health insurance board and all health services provided to these patients were retrieved for the 18 months prior to (baseline) and after (follow-up) the physicians' entry into practice. Medical service and prescription claims files were used to measure rates of resource use (specialty consultation, symptom-relief prescribing compared with disease-specific prescribing) and quality of care (inappropriate prescribing, mammography screening). Baseline data were used to adjust for differences in practice population. RESULTS: Study physicians saw a total of 1116389 patients, of whom 113535 (10.2%) were elderly and 83391 (7.5%) were women aged 50 to 69 years. Physicians with higher licensing examination scores referred more of their patients for consultation (3.8/1000 patients per SD increase in score; 95% confidence interval [CI], 1.2-7.0; P = .005), prescribed to elderly patients fewer inappropriate medications (-2.7/1000 patients per SD increase in score; 95% CI, -4.8 to -0.7; P=.009) and more disease-specific medications relative to symptom-relief medications (3.9/1000 patients per SD increase in score; 95% CI, 0.3 to 7.4; P= .03), and referred more women aged 50 to 69 years (6.6/1000 patients per SD increase in score; 95% CI, 1.2-11.9; P = .02) for mammography screening. If patients of physicians with the lowest scores had experienced the same rates of consultation, prescribing, and screening as patients of physicians with the highest scores, an additional 3027 patients would have been referred, 179 fewer elderly patients would have been prescribed symptom-relief medication, 912 more elderly patients would have been prescribed disease-specific medication, 189 fewer patients would have received inappropriate medication, and 121 more women would have received mammography screening. CONCLUSIONS: Licensing examination scores are significant predictors of consultation, prescribing, and mammography screening rates in initial primary care practice.

[Evaluation of clinical competence in urology: innovative approach based on performance observation]. / Evaluation de la compétence clinique en urologie: approche innovatrice basée sur l'observation de la performance.

OBJECTIVE: The authors present a pilot project for the evaluation of clinical skills in urology using a method of evaluation based on observation of real performance. MATERIAL AND METHODS: An objective and structured clinical examination (OSCE) applied to urology was developed according to a precise predetermined design: 1) Identification of the objectives to be evaluated. 2) Choice of sampling of clinical situations representative of routine urological practice. 3) Construction, on the basis of these cases, of physician-patient interaction stations and question stations, with, for each case, weighting of objectives, construction of observation grids and writing of instructions for candidates, simulated patients and observers. RESULTS: An OSCE circuit of 10 clinical cases and 16 stations was constructed. The main poles of activity and urological settings were represented. Objective complementary investigations, diagnosis and treatment received the highest weightings. The reliability coefficient, the content validity and the construct validity will be verified on the basis of the overall score obtained by candidate. CONCLUSION: Establishment of the score and the expected results in terms of reliability, validity, and feasibility are discussed. The psychometric qualities of the OSCE have been demonstrated. Although a single instrument is not sufficient, it is currently the measuring tool which most closely approximates ideal evaluation of clinical skills. If the feasibility of this method is confirmed, this pilot project in urology could provide a new approach to evaluation strategies and could participate in the current reflection concerning urology training.

Using standardized patients in licensing/certification examinations: comparison of two tests in Canada.

BACKGROUND: A new licensing examination for family physicians was introduced in the Province of Quebec, Canada, in 1990. It contains a newly developed, standardized, patient-based objective structured clinical examination (OSCE) used in complementarity with two other instruments (Short Answers Management Problems [SAMPs] and Simulated Office Orals [SOOs]) that have been used for many years by the College of Family Physicians of Canada (CFPC) for certification purposes. This research studied the criterion validity of the OSCE using the last instruments as criteria. METHODS: The results of the 172 spring 1994 candidates were analyzed. Cronbach alpha reliability coefficients were computed. Pearson's correlation coefficients and regression analysis measured the extent to which scores on the new Quebec OSCE correlated with the scores on the CFPC instruments. RESULTS: Correlation coefficients were significant between the Quebec OSCE scores and the CFPC examination total scores (.700), the SAMPs scores (.634), and the SOOs scores (.514). Multiple regression analysis confirmed that scores on the Quebec OSCE explained a significant but still limited proportion of the variation in scores of the CFPC examination. DISCUSSION: This study supports the criterion validity of the Quebec OSCE used in the licensing examination. However, differences in the skills assessed by each instrument and in the clinical situations presented exist between the Quebec instrument and the two national instruments. These differences, plus the variation in the scores obtained by the candidates on the three instruments, support the decision of the Quebec licensing organization to use them in complementarity.

Content validity of the Quebec licensing examination (OSCE). Assessed by practising physicians.

OBJECTIVE: To assess content validity of the objective structured clinical examination (OSCE), which uses multiple encounters with standardized patients and which is included in the Quebec licensing examination (QLEx). DESIGN: Descriptive study using written questionnaires based on Likert-type scales. SETTING: Examination centres of the QLEx. PARTICIPANTS: Thirteen practising family physicians with 3 to 6 years' practice experience who passed the QLEx OSCE in May 1993. MAIN OUTCOME MEASURES: Opinion whether the QLEx OSCE globally measured the competence of family physicians; opinion whether OSCE cases and stations made it possible to assess the main clinical abilities required of a family physician; opinion on specific statements about each case, such as how frequently the case was seen in the participants' practice, if the participants knew how to deal with the problem, if the simulated patient was believable, if the clinical situation was realistic, and if the duration of the station was adequate; and participants' self-assessment of their performance on the case. RESULTS: Eleven participants (84.6%) agreed that the OSCE globally measured the competence of a family physician. All agreed that the OSCE cases and stations made it possible to assess the main clinical skills required of a family physician. For most of the cases, participants believed that they knew how to deal with the problem, that the clinical situation was realistic, that the simulated patient was believable, and that the case duration was adequate. CONCLUSIONS: The results of this study support the content validity of the QLEx OSCE and confirm that it assesses the main skills needed for practising family medicine and adequately samples possible encounters or cases seen in family practice.

Residency directors' predictions of candidates' performances on a licensing examination.

PURPOSE: To look at how well residency directors in family medicine predict the performances of their candidates on the Quebec Licensing Examination (QLEx) for family physicians. METHOD: The four family medicine program directors in Quebec were asked in the spring of 1992 to identify the ten residents from their own programs who would get the highest marks on the QLEx and the ten who would get the lowest marks. From the results of these candidates, and those of the intermediate groups defined by default, the prediction abilities of the program directors were assessed. RESULTS: Descriptive statistics showed that the program directors had difficulties discriminating among the different groups and tended to collapse the predicted scores toward the total mean. Analysis-of-variance studies confirmed the absence of difference between the predicted weak and intermediate groups as well as between the predicted intermediate and strong groups for each program and for each QLEx component. Regression analysis as well as eta 2 studies showed that the program directors' prediction abilities were low for all components and represented less than 25% of the explained variance of the QLEx scores. CONCLUSION: The residency directors did not accurately categorize their residents' performances on the QLEx. Both the evaluations of program directors and terminal examination results are complementary approaches to clinical competence assessment and should be used for licensure.

Canadian experience with structured clinical examinations.

The use of structured clinical examinations to improve the evaluation of medical students and graduates has become significantly more common in the past 25 years. Many Canadian medical educators have contributed to the development of this technique. The Canadian experience is reviewed from the introduction of simulated-standardized patients and objective-structured clinical examinations to more recent developments and the use of such examinations for licensure and certification.

Large-scale use of an objective, structured clinical examination for licensing family physicians.

Since 1988 in Quebec the completion of a residency training program in family medicine or a specialty and of a comprehensive examination has been necessary to obtain a licence. An objective, structured clinical examination (OSCE) was designed by the Corporation professionnelle des médecins du Québec and Quebec's four medical schools to evaluate the clinical competence of newly trained family physicians. The certification examination of the College of Family Physicians of Canada was added to the OSCE. More than 500 candidates have been assessed: 262 in the spring of 1990, 42 in the fall of 1990 and 235 in the spring of 1991. The spring session occurs in four centres, three offering it in French and one in English, and the fall session takes place in one bilingual centre. In each centre 25 standardized patients and 25 examiners are required on each day of the 2-day OSCE. The scores obtained by the candidates who completed the OSCE in the first three sessions showed a normal distribution. No more than 5% failed the OSCE, the pass level having been set at two standard deviations below the mean. Equivalence was shown among the OSCE tracks, and reliability coefficients of 0.644, 0.723 and 0.736 were obtained for the three sessions respectively. The overall success rate for the licensing examination was 92%. The integration of such a large-scale OSCE into a licensing examination and the results obtained show that assessment of clinical competence for licensing purposes is feasible. The Quebec experience may help other organizations that are developing OSCEs for summative purposes.

Preparing faculty to teach in a problem-based learning curriculum: the Sherbrooke experience.

Over the last 6 years Sherbrooke Medical School has undertaken a major reform of its undergraduate curriculum. A new student-centred, community-oriented curriculum was implemented in September 1987. Problem-based learning (PBL) is now the main educational method. To adequately prepare teachers for the curriculum a series of faculty development programs in pedagogy were offered: first, a 2-day introductory workshop to initiate teachers into educational principles and their application in the new program; second, a 1-year basic training program in medical pedagogy; third, a 1-day workshop on PBL; and fourth, a comprehensive 3-day training program in PBL tutoring. Over 60% of all full-time teachers attended the introductory program and 80% the tutor training program. The 1-year basic training program was completed by 33% of the faculty members. The implementation of these programs, coupled with a high participation rate, resulted in a more student-centred educational philosophy and a greater interest in medical education. This had a significant impact when the new curriculum was instituted. Lessons learned from the experience are discussed.

Colon and rectum rigid and flexible endoscopy.

The authors examined results of 1046 of the 1268 endoscopic examinations performed from July 1982 to June 1986 in a family practice unit. A flexible sigmoidoscope of 60 cm or more was used for 77% of the examinations. Data were collected from patients' charts and analyzed by computer in collaboration with a research methodologist. Screening for colorectal cancer was the reason for the examination in 287 patients (27.4%). More than 60% of the examinations were performed on patients with digestive symptoms. Miscellaneous colorectal diseases were diagnosed; more than 12% of the patients had at least one polyp with a diameter of 5 mm or more. Nine patients (0.86%) had cancer, and one patient had two primary tumours. Three of the nine patients were asymptomatic, and four had blood in their stools. Six patients had cancers found at a very early stage of development.

A program of faculty development in family medicine.

This article describes one teacher's experience in a program of faculty development offered by the University of Western Ontario, Department of Family Medicine. Faculty development is summarized according to faculty's four roles: clinician, teacher, administrator and researcher. Emphasis is put on self-growth and development. The difficulties encountered after a sabbatical leave are briefly discussed.

Small erythematous mucosal plaques: an endoscopic sign of Crohn's disease.

A non-ulcerated granulomatous lesion of the large bowel mucosa has been found in 11 patients, nine of whom already had or eventually developed classical features of Crohn's disease. These lesions, which are multiple, consist of small well-circumscribed raised erythematous plaques surrounded by normal mucosa. At biopsy there is focal haemorrhage of the lamina propria, rupture of the crypts, release of mucus, and frank granulomatous reaction with giant cell formation. The lesion may be reversible or be followed by the classical mucosal ulcerations. They may occur in the presence or the absence of classical lesions of Crohn's disease elsewhere in the gastrointestinal tract. As this non-ulcerated lesion may occur in isolation, it may provide the initial clue to the diagnosis of Crohn's disease.