Implementación de la reforma curricular de la Escuela de Medicina de la Pontificia Universidad Católica de Chile: analizando la experiencia / Implementation of curricular changes at a medical school

The accelerated scientific, technological, and social advances in recent years have posed new challenges for professional training institutions, where universities play a leading role. Medical schools have not been oblivious to this process. This is how Pontificia Universidad Católica de Chile implemented in 2015 a curricular reform derived from the joint work of academics, students and graduates. For this purpose, a model consisting of stages was followed, including the identification of the problem, general assessment of needs, definition of purpose and learning objectives. We worked with surveys, focus groups and committees of academics and students to identify and map content within the mesh, review terminal learning objectives while creating and reviewing courses for the vertically and horizontally integrated delivery of content and competencies. The first cohort of the new curriculum entered in 2015, consisting of 126 students. The implementation required constant follow-up and monitoring, establishing changes and adjustments according to educational needs and unforeseen conditions such as the COVID-19 pandemic. The implementation process of the new curriculum has been positive, adjusting to the defined strategic planning and responding to unexpected events.

[Implementation of curricular changes at a medical school]. / Implementación de la reforma curricular de la Escuela de Medicina de la Pontificia Universidad Católica de Chile: analizando la experiencia.

The accelerated scientific, technological, and social advances in recent years have posed new challenges for professional training institutions, where universities play a leading role. Medical schools have not been oblivious to this process. This is how Pontificia Universidad Católica de Chile implemented in 2015 a curricular reform derived from the joint work of academics, students and graduates. For this purpose, a model consisting of stages was followed, including the identification of the problem, general assessment of needs, definition of purpose and learning objectives. We worked with surveys, focus groups and committees of academics and students to identify and map content within the mesh, review terminal learning objectives while creating and reviewing courses for the vertically and horizontally integrated delivery of content and competencies. The first cohort of the new curriculum entered in 2015, consisting of 126 students. The implementation required constant follow-up and monitoring, establishing changes and adjustments according to educational needs and unforeseen conditions such as the COVID-19 pandemic. The implementation process of the new curriculum has been positive, adjusting to the defined strategic planning and responding to unexpected events.

Epistemonikos: a comprehensive database of systematic reviews for health decision-making.

BACKGROUND: Systematic reviews allow health decisions to be informed by the best available research evidence. However, their number is proliferating quickly, and many skills are required to identify all the relevant reviews for a specific question. METHODS AND FINDINGS: We screen 10 bibliographic databases on a daily or weekly basis, to identify systematic reviews relevant for health decision-making. Using a machine-based approach developed for this project we select reviews, which are then validated by a network of more than 1000 collaborators. After screening over 1,400,000 records we have identified more than 300,000 systematic reviews, which are now stored in a single place and accessible through an easy-to-use search engine. This makes Epistemonikos the largest database of its kind. CONCLUSIONS: Using a systematic approach, recruiting a broad network of collaborators and implementing automated methods, we developed a one-stop shop for systematic reviews relevant for health decision making.

System-Wide Accelerated Implementation of Telemedicine in Response to COVID-19: Mixed Methods Evaluation.

BACKGROUND: As the COVID-19 pandemic disrupted medical practice, telemedicine emerged as an alternative to outpatient visits. However, it is not known how patients and physicians responded to an accelerated implementation of this model of medical care. OBJECTIVE: The aim of this study is to report the system-wide accelerated implementation of telemedicine, compare patient satisfaction between telemedicine and in-person visits, and report provider perceptions. METHODS: This study was conducted at the UC Christus Health Network, a large private academic health network in Santiago, Chile. The satisfaction of patients receiving telemedicine care in March and April 2020 was compared to those receiving in-person care during the same period (concurrent control group) as well as in March and April 2019 (retrospective control group). Patient satisfaction with in-person care was measured using the Net Promoter Score (NPS) survey. Patient satisfaction with telemedicine was assessed with an online survey assessing similar domains. Providers rated their satisfaction and responded to open-ended questions assessing challenges, strategies used to address challenges, the diagnostic process, treatment, and the patient-provider relationship. RESULTS: A total of 3962 patients receiving telemedicine, 1187 patients from the concurrent control group, and 1848 patients from the retrospective control group completed the surveys. Satisfaction was very high with both telemedicine and in-person services. Overall, 263 physicians from over 41 specialties responded to the survey. During telemedicine visits, most providers felt their clinical skills were challenged (61.8%). Female providers felt more challenged than male providers (70.7% versus 50.9%, P=.002). Surgeons, obstetricians, and gynecologists felt their clinical skills were challenged the least, compared to providers from nonsurgical specialties (P<.001). Challenges related to the delivery modality, diagnostic process, and patient-provider relationship differed by provider specialty (P=.046, P<.001, and P=.02, respectively). CONCLUSIONS: Telemedicine implemented in response to the COVID-19 pandemic produced high patient and provider satisfaction. Specialty groups perceived the impact of this new mode of clinical practice differently.

Communication skills training for healthcare professionals working with people who have cancer.

BACKGROUND: This is the third update of a review that was originally published in the Cochrane Library in 2002, Issue 2. People with cancer, their families and carers have a high prevalence of psychological stress, which may be minimised by effective communication and support from their attending healthcare professionals (HCPs). Research suggests communication skills do not reliably improve with experience, therefore, considerable effort is dedicated to courses that may improve communication skills for HCPs involved in cancer care. A variety of communication skills training (CST) courses are in practice. We conducted this review to determine whether CST works and which types of CST, if any, are the most effective. OBJECTIVES: To assess whether communication skills training is effective in changing behaviour of HCPs working in cancer care and in improving HCP well-being, patient health status and satisfaction. SEARCH METHODS: For this update, we searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 4), MEDLINE via Ovid, Embase via Ovid, PsycInfo and CINAHL up to May 2018. In addition, we searched the US National Library of Medicine Clinical Trial Registry and handsearched the reference lists of relevant articles and conference proceedings for additional studies. SELECTION CRITERIA: The original review was a narrative review that included randomised controlled trials (RCTs) and controlled before-and-after studies. In updated versions, we limited our criteria to RCTs evaluating CST compared with no CST or other CST in HCPs working in cancer care. Primary outcomes were changes in HCP communication skills measured in interactions with real or simulated people with cancer or both, using objective scales. We excluded studies whose focus was communication skills in encounters related to informed consent for research. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials and extracted data to a pre-designed data collection form. We pooled data using the random-effects method. For continuous data, we used standardised mean differences (SMDs). MAIN RESULTS: We included 17 RCTs conducted mainly in outpatient settings. Eleven trials compared CST with no CST intervention; three trials compared the effect of a follow-up CST intervention after initial CST training; two trials compared the effect of CST and patient coaching; and one trial compared two types of CST. The types of CST courses evaluated in these trials were diverse. Study participants included oncologists, residents, other doctors, nurses and a mixed team of HCPs. Overall, 1240 HCPs participated (612 doctors including 151 residents, 532 nurses, and 96 mixed HCPs).Ten trials contributed data to the meta-analyses. HCPs in the intervention groups were more likely to use open questions in the post-intervention interviews than the control group (SMD 0.25, 95% CI 0.02 to 0.48; P = 0.03, I² = 62%; 5 studies, 796 participant interviews; very low-certainty evidence); more likely to show empathy towards their patients (SMD 0.18, 95% CI 0.05 to 0.32; P = 0.008, I² = 0%; 6 studies, 844 participant interviews; moderate-certainty evidence), and less likely to give facts only (SMD -0.26, 95% CI -0.51 to -0.01; P = 0.05, I² = 68%; 5 studies, 780 participant interviews; low-certainty evidence). Evidence suggesting no difference between CST and no CST on eliciting patient concerns and providing appropriate information was of a moderate-certainty. There was no evidence of differences in the other HCP communication skills, including clarifying and/or summarising information, and negotiation. Doctors and nurses did not perform differently for any HCP outcomes.There were no differences between the groups with regard to HCP 'burnout' (low-certainty evidence) nor with regard to patient satisfaction or patient perception of the HCPs communication skills (very low-certainty evidence). Out of the 17 included RCTs 15 were considered to be at a low risk of overall bias. AUTHORS' CONCLUSIONS: Various CST courses appear to be effective in improving HCP communication skills related to supportive skills and to help HCPs to be less likely to give facts only without individualising their responses to the patient's emotions or offering support. We were unable to determine whether the effects of CST are sustained over time, whether consolidation sessions are necessary, and which types of CST programs are most likely to work. We found no evidence to support a beneficial effect of CST on HCP 'burnout', the mental or physical health and satisfaction of people with cancer.

Do clinicians want recommendations? A multicenter study comparing evidence summaries with and without GRADE recommendations.

OBJECTIVES: Evidence-based clinical practice guidelines provide recommendations to assist clinicians in decision-making and to reduce the gap between best current research evidence and clinical practice. However, some argue that providing preappraised evidence summaries alone, rather than recommendations, is more appropriate. The objective of the study is to evaluate clinicians' preferences, and understanding of the evidence and intended course of action in response to evidence summaries with and without recommendations. STUDY DESIGN SETTING: We included practicing clinicians attending educational sessions across 10 countries. Clinicians were randomized to receive relevant clinical scenarios supported by research evidence of low or very low certainty and accompanied by either strong or weak recommendations developed with the GRADE system. Within each group, participants were further randomized to receive the recommendation plus the corresponding evidence summary or the evidence summary alone. We evaluated participants' preferences and understanding for the presentation strategy, as well as their intended course of action. RESULTS: One hundred eighty-nine of 219 (86%) and 201 of 248 (81%) participants preferred having recommendations accompanying evidence summaries for both strong and weak recommendations, respectively. Across all scenarios, less than half of participants correctly interpreted information provided in the evidences summaries (e.g., estimates of effect, certainty in the research evidence). The presence of a recommendation resulted in a more appropriate intended course of action for two scenarios involving strong recommendations. CONCLUSION: Evidence summaries alone are not enough to impact clinicians' course of action. Clinicians clearly prefer having recommendations accompanying evidence summaries in the context of low or very low certainty of evidence (Trial registration NCT02006017).

[Curriculum reform at the Pontificia Universidad Católica de Chile School of Medicine]. / Reforma curricular de la carrera de Medicina de la Pontificia Universidad Católica de Chile.

The career of Medicine at the Pontificia Universidad Católica de Chile was established from the beginning (1929), with a classical Flexner curriculum design. In seven years, the career is divided in three cycles: basic sciences, clinics and internship. It obtained Chilean accreditation and fulfilled American Association of Medical Colleges accreditation requirements. Changes in the Chilean epidemiological profile and health system, and new teaching methods in medicine, stimulated a process of deep curricular analysis, identifying strengths and weaknesses of the medical career. The curricular strengths were well-developed scientific and clinical components, fully committed students and faculties, well defined learning objectives and excellent clinical campuses. Curricular weaknesses included a poor vertical and horizontal integration, few student centered methodologies and a weak emphasis concerning doctor’s professionalism. Subsequently, the whole community of teachers, students and medical educators worked on the design of a new curriculum, establishing a new graduate profile and designed it oriented by learning objectives, of six years of duration, with an optimized course sequence that melds basic science and clinical concepts, with strong emphasis on humanities and professionalism. It prioritizes an early contact with patients from the first year and expands teaching methods. The main objective of this process was to achieve a new curriculum with an integrative structure. This was implemented in 2015 with an approved protocol to evaluate the outcomes.

Home care learning model for medical students in chile: a mixed methods study.

Introduction. The relevance of home care training is not questioned. However, there are no reported learning models to teach in this setting. Aims. To develop and evaluate a learning model to teach home care to medical students. Methods. Stage 1: Learning Model Design. Tutors teaching home care and a sample of medical students were invited to focus groups analyzed according to the grounded theory. Later, the researchers designed the learning model, which was approved by all participants. Stage 2: Learning Assessment. All students in their family medicine internship at Pontificia Universidad Catolica de Chile were invited to participate in a nonrandomized before-and-after pilot trial, assessing changes in their perception towards home care and satisfaction with the learning model. Results. Stage 1: Six tutors and eight students participated in the focus groups. The learning model includes activities before, during, and after the visits. Stage 2: 105 students (88.2%) participated. We observed improvement in all home care training domains (P ≤ 0.001) and a high satisfaction with the model. Students with previous home visit experiences and who participated with nurses and social workers reported more learning. Conclusions. We report an effective learning model to train medical students in home care. Limitations and recommendations for future studies are discussed.

How much survival benefit is necessary for breast cancer patients to opt for adjuvant chemotherapy? Results from a Chilean survey.

BACKGROUND: Breast cancer (BC) is the leading cause of cancer death in Chilean women. Adjuvant chemotherapy decreases recurrence and death from BC. The recommendation to indicate chemotherapy is complex. Adjuvant! Online is a valuable computational tool to predict survival benefit obtained with adjuvant systemic therapy. Previous studies in Caucasian patients with BC showed that they are willing to receive chemotherapy for a small benefit. No studies, to our knowledge, have been done in the Hispanic or Latino populations. METHODS: We interviewed females with BC who had previously received adjuvant chemotherapy. Age, stage at presentation, time since last chemotherapy, type of chemotherapy, marital status, number of children, and level of education were recorded. We used the graphic representation from Adjuvant! Online to question each patient on how much survival benefit she required to accept chemotherapy. RESULTS: There were 101 women surveyed. The average age was 55.9 (±10.2), 54.5% had involved lymph nodes, 59.4% were married, and 15.8% did not have parity; 62.3% of females accepted chemotherapy for an absolute survival benefit of 1% or less. In a multivariate analysis, younger (p = 0.02) and less-educated patients (p = 0.018) were associated with lower survival benefit required to opt for chemotherapy. CONCLUSION: In our study, the acceptance of chemotherapy by the Hispanic population requires minimal survival benefit and is in agreement with the Caucasian population reported elsewhere. To our knowledge, our report is the first study that evaluates the perception of Latino patients regarding the benefit of chemotherapy in early BC.

Effectiveness of a brief intervention based on the '5A' model for smoking cessation at the primary care level in Santiago, Chile.

Chilean women have the highest smoking rates in Latin America. Prevalence in this population is about 40%. There are no national programs for smoking cessation at the primary care level. This study explores the feasibility and effectiveness of a brief counseling intervention targeted to women smokers of childbearing age who seek primary care in Santiago, Chile. A quasi-experimental design was used to compare the effect of an intervention based on the '5A' model developed by the National Cancer Institute in the United States and the standard care provided in two control clinics. Women smokers seeking care at the three primary care clinics were contacted during a 2 months period and offer to participate in the study. Sampling was stratified according to the age groups to ensure comparability between cohorts. Quotas were calculated for each age group. Participants were asked about their willingness to quit, self-efficacy, smoking behavior, addiction level as well as support received for smoking cessation. After 18 months of intervention all women were re-evaluated. A total of 773 women were recruited for the study; 76% of them completed the trial. Women smokers are characterized by a large percentage of light smokers with a low self-efficacy for quitting and with very low information on where and how to get assistance to quit. At study end, 15.2% of women reported quitting smoking at least for 1 month in the intervention clinic versus 7.8% in one of the control clinics (p < 0.05) and 14.6% in the second control clinic (p = NS). Over 70% of women in the intervention clinic were asked, assessed and received advice for quitting in comparison with <15% in the control clinics (p < 0.01). To conclude, a primary care intervention based on the '5A' model for smoking cessation is feasible and can have a significant effect in reducing smoking prevalence in this population.

[Smoking interventions in primary health care: smoking profile of women and beliefs and attitudes of local health care teams]. / Tabaquismo en Atención Primaria: Perfil de fumadoras consultantes, creencias y actitudes de los equipos de salud y oportunidades de intervención.

BACKGROUND: Chile has one of the highest prevalence rate of smoking in the world. Brief counseling interventions for smoking cessation at the primary health care level are effective. Compliance with counseling intervention is strongly associated with beliefs and attitudes of the primary health care team that deliver it. The effectiveness of these interventions improve if they are applied to smoking populations with higher motivation of change and high self-efficacy for quitting. AIM: To study the smoking profile of a group of smoking women in Santiago and to identify beliefs and attitudes of the primary health care team members to implement smoking cessation interventions. MATERIAL AND METHODS: A cross-sectional design that included 306 women smokers attending two primary health care clinics in Santiago. Perceptions, beliefs and attitudes of 34 primary care team members from three clinics in Santiago were explored using a qualitative methodology. RESULTS: The study identified a subgroup of 18% of women highly motivated to quit (decisional stage of change) and a 58% with a high self-efficacy. Beliefs and attitudes of staff at the clinics were characterized by invisibility, ambivalence and fatalism regarding the effectiveness of smoking cessation interventions. CONCLUSIONS: There is a subgroup of smoking women with a high probability of quitting if they receive an appropriate counseling. Developing a systematic approach for smoking cessation intervention at the primary care setting in Chile should consider the invisibility, ambivalence and fatalism of primary health care team members towards this topic.