Challenging cases during clinical clerkships beyond the domain of the "medical expert": an analysis of students' case vignettes.

Background: During clinical clerkships students experience complex and challenging clinical situations related to problems beyond the domain of the "Medical Expert". Workplace routine may leave little opportunity to reflect on these situations. The University of Zurich introduced a mandatory course directly after the clinical clerkship year (CCY) to work up these situations. Prior to the course each student submitted a vignette on a case he or she had perceived challenging during the CCY and which was not related to the domain of the "Medical Expert" role. In this paper we want to characterize these cases in respect to most prominent themes and related CanMEDS roles. The goal was to inform clinical supervisors about potential teaching demands during the CCY. Methods: All case vignettes submitted by a years' cohort were analysed by three researchers in two ways: for the clinical characteristics and the main theme of the underlying problem and the most prominent CanMEDS roles involved. Themes of the underlying problem were aggregated to overarching topics and subsequently to main categories by pragmatic thematic analysis. Results: 254 case vignettes covered the whole spectrum of clinical disciplines. A wide range of underlying themes could be assigned to five main categories: "communication within team" (23.2%), "communication with patients and relatives" (24.8%), "patient behavior and attitudes" (18.5%), "clinical decision making" (24.0%), and "social and legal issues" (9.4%). Most frequent CanMEDS roles were "Communicator" (26.9%) and "Professional" (23.5%). Conclusions: Cases students perceived as challenging beyond the "Medical Expert" were reported from all clinical disciplines. These were mainly related to communicational and professional issues, mirrored by the CanMEDS roles "Communicator" and "Professional". Therefore, supervisors in clinical clerkships should put an additional teaching focus on communication and professionalism.

The multimorbidity interaction severity index (MISI): A proof of concept study.

Therapeutic decision-making for patients with multimorbidity (MM) is challenging. Clinical practice guidelines inadequately address harmful interactions and resulting therapeutic conflicts within and among diseases. A patient-specific measure of MM severity that takes account of this conflict is needed.As a proof of concept, we evaluated whether the new Multimorbidity Interaction Severity Index (MISI) could be used to reliably differentiate patients in terms of lower versus higher potential for harmful interactions.Two hypothetical patient cases were generated, each with 6 concurrent morbidities. One case had a low (i.e., low conflict case) and the other a high (i.e., high conflict case) potential for harmful interactions. All possible interactions between conditions and treatments were extracted from each case's record into a multimorbidity interaction matrix. Experienced general internists (N = 18) judged each interaction in the matrix in terms of likely resource utilization needed to manage the interaction. Based on these judgements, a composite index of MM interaction severity, that is, the MISI, was generated for each physician and case.The difference between each physician's MISI score for the 2 cases (MISIdiff) was computed. Based on MISIdiff, the high conflict case was judged to be of significantly greater MM severity than was the low conflict case. The positive values of the inter-quartile range, a measure of variation (or disagreement) between the 2 cases, indicated general consistency of individual physicians in judging MM severity.The data indicate that the MISI can be used to reliably differentiate hypothetical multimorbid patients in terms of lesser versus greater severity of potentially harmful interactive effects. On this basis, the MISI will be further developed for use in patient-specific assessment and management of MM. The clinical relevance of the MISI as an alternative approach to defining MM severity is discussed.

Check-up examination: recommendations in adults.

Check-up examinations, or periodic health examinations (PHEs), have gained in importance during the last decades and are nowadays among the most common reasons for consultations in primary care settings. The aim of PHEs is to identify risk factors and early signs of disease, but also to prevent future illness by early intervention. Therefore, each PHE should include counselling, immunisation and physical examination according to the patient's age and gender. However, deciding whether to screen a patient and choosing the most appropriate screening method can be challenging for general practitioners. The U.S. Preventive Service Task Force (USPSTF) provides updated recommendations on different existing preventive care measures based on relevant literature review. The aim of this review is to provide an updated statement of recommendations regarding preventive care measures based mostly on the guidelines derived from the USPSTF and the Swiss Medical Board. Among the major updates, there is no recommendation anymore to routinely screen for breast cancer and prostate cancer in asymptomatic adults. Since 2013, however, the USPSTF recommends annual screening for lung cancer with low-dose CT in patients aged 55 to 80 years with a smoking history of ≥30 pack years. During PHEs, the physician should be alert to the patients' hidden agendas, which are the reason for one third of all consultations in primary care.