Patient involvement in assessment of postgraduate medical learners: A scoping review.

CONTEXT: Competency-based assessment of learners may benefit from a more holistic, inclusive, approach for determining readiness for unsupervised practice. However, despite movements towards greater patient partnership in health care generally, inclusion of patients in postgraduate medical learners' assessment is largely absent. METHODS: We conducted a scoping review to map the nature, extent and range of literature examining the inclusion (or exclusion) of patients within the assessment of postgraduate medical learners. Guided by Arskey and O'Malley's framework and informed by Levac et al. and Thomas et al., we searched two databases (MEDLINE® and Embase®) from inception until February 2021 using subheadings related to assessment, patients and postgraduate learners. Data analysis examined characteristics regarding the nature and factor influencing patient involvement in assessment. RESULTS: We identified 41 papers spanning four decades. Some literature suggests patients are willing to be engaged in assessment, however choose not to engage when, for example, language barriers may exist. When stratified by specialty or clinical setting, the influence of factors such as gender, race, ethnicity or medical condition seems to remain consistent. Patients may participate in assessment as a stand-alone group or part of a multi-source feedback process. Patients generally provided high ratings but commented on the observed professional behaviours and communication skills in comparison with physicians who focused on medical expertise. CONCLUSION: Factors that influence patient involvement in assessment are multifactorial including patients' willingness themselves, language and reading-comprehension challenges and available resources for training programmes to facilitate the integration of patient assessments. These barriers however are not insurmountable. While understudied, research examining patient involvement in assessment is increasing; however, our review suggests that the extent which the unique insights will be taken up in postgraduate medical education may be dependent on assessment systems readiness and, in particular, physician readiness to partner with patients in this way.

"Part of the Ritual": Exploring Patient and Physician Decision Making Regarding Anticoagulation Use in Obstetric Antiphospholipid Syndrome.

BACKGROUND: Antiphospholipid syndrome is associated with recurrent pregnancy loss. Low-molecular-weight heparin (LMWH) and/or aspirin (ASA) prophylaxis during pregnancy to prevent future loss is based on limited trial data with mixed results. OBJECTIVES: Given the clinical equipoise, we sought to understand how patients and physicians navigate the decision-making process for use of LMWH and/or ASA in pregnancy. METHODS: We interviewed 10 patients and 10 thrombosis physicians in Ottawa, Canada from January 2017 to March 2018. Patients who had ≥1 late pregnancy loss or ≥2 early losses and persistently positive antiphospholipid antibodies based on the revised Sapporo/Sydney criteria were identified in the a Thrombosis Clinic. Patients were also identified by the TIPPS Study screening logs of excluded patients. Data collection and analysis occurred iteratively, in keeping with constructivist grounded theory methodology. RESULTS: Our analysis generated three themes, present across both patient and physician interviews, which captured a patient-led decision-making experience: (1) managing high stakes, (2) accepting uncertainty, and (3) focusing on safety. Patients and physicians acknowledged the high emotional burden and what was at stake: avoiding further pregnancy loss. Patients responded to their situation by taking action (i.e., using LMWH injections became a "ritual"), whereas physicians reacted by removing themselves from the final decision by "[leaving] it up to the patient." CONCLUSION: Our findings should be considered when designing future research on studying the role for LMWH/ASA in this population, as it suggests that the perceived benefits of treatment go beyond improving pregnancy rates. Rather, patients described potential benefit from the process of taking action, even in the absence of a guaranteed good outcome.

Establishing diagnostic criteria and treatment of subsegmental pulmonary embolism: A Delphi analysis of experts.

BACKGROUND: Improved imaging techniques have increased the incidence of subsegmental pulmonary embolism (ssPE). Indirect evidence is suggesting that ssPE may represent a more benign presentation of venous thromboembolism not necessarily requiring anticoagulant treatment. However, correctly diagnosing ssPE is challenging with reported low interobserver agreement, partly due to the lack of widely accepted diagnostic criteria. OBJECTIVES: We sought to derive uniform diagnostic criteria for ssPE, guided by expert consensus. METHODS: Based on an extensive literature review and expert opinion of a Delphi steering committee, two surveys including statements regarding diagnostic criteria and management options for ssPE were established. These surveys were conducted electronically among two panels, respectively: expert thoracic radiologists and clinical venous thromboembolism specialists. The Delphi method was used to achieve consensus after multiple survey rounds. Consensus was defined as a level of agreement >70%. RESULTS: Twenty-nine of 40 invited radiologists (73%) and 40 of 51 clinicians (78%) participated. Following two survey rounds by the expert radiologists, consensus was achieved on 15 of 16 statements, including on the established diagnostic criteria for ssPE (96% agreement): a contrast defect in a subsegmental artery, that is, the first arterial branch division of any segmental artery independent of artery diameter, visible in at least two subsequent axial slices, using a computed tomography scanner with a desired maximum collimator width of ≤1 mm. These criteria were approved by 83% of the clinical venous thromboembolism (VTE) specialists. The clinical expert panel favored anticoagulant treatment in case of prior VTE, antiphospholipid syndrome, pregnancy, cancer, and proximal deep vein thrombosis. CONCLUSION: The results of this analysis provide standard radiological criteria for ssPE that may be applicable in both clinical trials and practice.

A pilot study of a longitudinal mindfulness curriculum in undergraduate medical education.

BACKGROUND: To support student well-being, a mindfulness curriculum in undergraduate medical education was launched at our university in 2014. We describe the program and report 3-year results. METHODS: Medical students responded to online questionnaires on mindfulness (Freiburg Mindfulness Inventory), empathy (Jefferson Scale of Physician Empathy), resilience (Connor-Davidson Resilience Scale) and perceived stress (Perceived Stress Scale) and were surveyed for demographics, home practice, and subjective experience at curriculum launch and yearly for 3 years. RESULTS: In respondents, high stress (19.2 (SD=6)) and low resilience (71.2 (SD=12.5)) scores were seen throughout training. Scores for mindfulness correlated positively with those for empathy (r=.217 p < 0.01) and resilience (r = .539, p < 0.01), and negatively with stress scores (r = -.380, p < 0.01). While overall scale scores did not statistically change after curriculum implementation, statistically significant increases were seen in mindfulness (12%, p = 0.008), empathy (5%, p = 0.045), and resilience scores (12%, p = 0.002) with a trend toward lower stress scores (8%, p =0.080) in respondents who felt they applied the curriculum principles. Two hours of reported home practice per week was associated with statistically significant changes (14% increased mindfulness scores p < 0.001; 6% increased empathy scores p < 0.001, 10% increased resilience scores p = 0.003; 11% decreased stress scores p = 0.008). Despite positive program evaluations for both mandatory and elective sessions, student attendance at elective sessions was low. CONCLUSION: A mindfulness curriculum integrated into formal undergraduate medical education is feasible. Benefits may be confined to those students who apply curriculum principles and practice regularly. Further study is needed.Résumé. CONTEXTE: Pour soutenir le bien-être des étudiants, un cursus de méditation pleine conscience dans le cadre du programme de doctorat en médecine a été lancé à notre université en 2014. Nous décrivons le programme et communiquons les résultats après trois ans. MÉTHODES: Des étudiants en médecine ont répondu à des questionnaires en ligne sur la pleine conscience (inventaire de pleine conscience de Freiburg), l'empathie (Échelle de Jefferson sur l'empathie du médecin), la résilience (échelle de résilience de Connor-Davidson) et le stress perçu (échelle du stress perçu) et ont été interrogés pour les caractéristiques démographiques, la pratique de la méditation pleine conscience à domicile et l'expérience subjective au moment du lancement du cursus et, ensuite, annuellement pendant trois ans. RÉSULTATS: Chez les répondants, un degré de stress élevé (19,2 (ET=6)) et une faible résilience (71,2 (ET=12,5)) ont été observés tout au long de la formation. Il y avait une corrélation positive entre les la pleine conscience et l'empathie (r=0,17, p<0,01) et de la résilience (r=0,539, p<0,01), et négative avec le stress (r=-0,380, p<0,01). Alors que les résultats globaux ne changent pas statistiquement après la mise en œuvre du cursus, des augmentations statistiquement significatives ont été observées pour la pleine conscience (12%, p=0,008), l'empathie (5%, p=0,045) et la résilience (12%, p=0,002) avec une tendance vers des résultats inférieurs pour le stress (8%, p=0,080) chez les répondants qui estimaient avoir appliqué les principes du programme. On retrouvait des changements significatifs chez les répondants qui rapportaient avoir pratiqué deux heures par semaine à domicile (résultats accrus de 14% pour la pleine conscience (p<0,001), de 6% pour l'empathie (p<0,001) et de 10% pour la résilience (p= 0,003), et réduits de 11% pour le stress (p=0,008)). Malgré des évaluations de programme positives pour les sessions obligatoires et optionnelles, l'assiduité des étudiants aux sessions optionnelles était faible. CONCLUSION: Un cursus de méditation pleine conscience intégré dans des études formelles de doctorat en médecine est faisable. Les avantages peuvent être confinés aux étudiants qui appliquent les principes du programme et qui le pratiquent sur une base régulière. D'autres études sont requises.

A case of acute pancreatitis-induced microangiopathic hemolytic anemia with thrombocytopenia.

Microangiopathic hemolytic anemia and thrombocytopenia (MAHA-T) is a rare complication of acute pancreatitis (AP). Treatment with therapeutic plasma exchange (TPE) is used at many centers. The natural history of this disease is not well understood. We report a case of acute pancreatitis induced MAHA-T with end organ dysfunction and a normal ADAMTS13 level. Following three TPEs, the patient's clinical status, blood counts and hemolytic markers stabilized. Improvement occurred even after TPE was discontinued. The optimal management of AP-induced MAHA-T is poorly understood. Many centres are reporting good outcomes with the early initiation of TPE. MAHA-T associated with acute pancreatitis is often treated with early initiation of TPE. However, the value of TPE in altering the natural history of the condition is not well understood. Further study is required to understand the role of ADAMTS13 testing to guide treatment, and the role of TPE in management.

Feasibility and effectiveness of an online mindfulness meditation program for medical students.

BACKGROUND: The need to incorporate tools to promote medical student wellness in medical education is underscored by the concerning rates of psychological distress among them. The objective of this prospective cohort study was to obtain preliminary data on the feasibility and effectiveness of an online mindfulness intervention for medical student wellness. METHODS: A convenience sample of 52 medical students consented to participate in this study. Feasibility was assessed by ease of recruitment, number of modules completed, satisfaction with the program, and adherence to a regular meditation practice. Participants completed the Maslach Burnout Inventory, the Jefferson Scale of Empathy-medical student version, the Five Face of Mindfulness Questionnaire-short form, and the Self Compassion Scale-short form pre and post intervention. RESULTS: The convenience sample was recruited within a two-month period. Forty-five participants completed at least one of seven modules. Descriptive statistics (mean±standard deviation) revealed that the mean number of modules completed was 4.85±2.7. Mean satisfaction with the modules was 7.07±1.1 out of 10. Adherence to a regular formal meditation practice was poor; the average amount of formal meditation practice per module was 34.14±27.44 minutes. Self-compassion and the "observe and describe" facets of mindfulness practice significantly statistically increased from baseline, but no such change was observed for levels of burnout and empathy. CONCLUSION: The present study indicates that an online mindfulness meditation program may be of interest to medical students. The results did not provide any evidence that the program was effective but we believe further research and development is warranted.

Transitioning towards senior medical resident: identification of the required competencies using consensus methodology.

BACKGROUND: Residency programs are facing significant restructuring through the "Competence by Design" (CBD) framework proposed by the Royal College of Physicians and Surgeons of Canada (RCPSC). Our goal was to establish the competencies to be acquired during the transition to a senior role within Internal Medicine (IM) training. METHODS: Using a modified Delphi technique, practicing IM physicians and recent graduates were polled to develop consensus on the required competencies to effectively transition from junior to senior medical resident. Participants rated each competency on a three-point Likert scale. Each competency was linked to an Entrustable Professional Activity (EPA) identified by the RCPSC IM Specialty Committee. RESULTS: A total of eighteen participants took part in item generation (16% response rate) and nineteen in the initial ranking with seventeen completing all three iterations (89% completion rate). Eighty-three competencies were identified during questionnaire development. A final list of seventy-seven competencies reached consensus after three rounds. Most competencies matched to core of discipline EPAs. CONCLUSION: This consensus-based list of competencies will help create a framework and tools for the assessment of junior residents as they prepare to transition to the role of senior in the new CBD curricula for IM trainees at our institution.

Guiding curriculum development of a national research training program in thrombosis medicine: A needs assessment involving faculty and trainees.

BACKGROUND: Several barriers exist for training and retention of clinician scientists, including difficulty in navigating research-related tasks in the workplace and insufficient mentorship. OBJECTIVE: Our aim was to identify what core research knowledge and skills are important for the success of clinician scientists in thrombosis research, and trainees' perceived confidence in those skills, in order to develop a targeted educational intervention. METHODS: A pre-tested online survey was administered to trainees and research faculty of the Canadian thrombosis research network, CanVECTOR, between September 2016 and June 2017. The importance (research faculty) and confidence (trainees) of 45 research knowledge/skills were measured using a 5-point Likert scale. RESULTS: The survey response rate was 49% (28/57) for research faculty and 100% (10/10) for trainees. All research faculty rated developing a good research question, grant writing and writing strategies for successful publication as 'very' or 'extremely' important for trainees to learn to better transition in becoming independent researchers. Other important areas included practical aspects of research. A qualitative thematic analysis of open text responses identified 'time management' and 'leadership and teamwork' as additional important research skills. Confidence reported for each topic varied across trainees. There were three research knowledge and/or skills that ≥75% of research faculty deemed highly important and ≥50% of trainees reported lacking confidence in: grant writing, the peer-review grant process, and knowledge translation strategies. CONCLUSIONS: Developing a good research question, communicating research ideas and results and the practical aspects of research are important areas to focus future efforts in thrombosis research training.

Identifying the factors influencing practice variation in thrombosis medicine: A qualitative content analysis of published practice-pattern surveys.

Practice variation, the differences in clinical management between physicians, is one reason why patient outcomes may differ. Identifying factors that contribute to practice variation in areas of clinical uncertainty or equipoise may have implications for understanding and improving patient care. To discern what factors may influence practice variation, we completed a qualitative content analysis of all practice-pattern surveys in thrombosis medicine in the last 10years. Out of 2117 articles screened using a systematic search strategy, 33 practice-pattern surveys met eligibility criteria. Themes were identified using constant comparative analysis of qualitative data. Practice variation was noted in all 33 practice-pattern surveys. Contributing factors to variation included lack of available evidence, lack of clear and specific guideline recommendations, past experience, patient context, institutional culture and the perceived risk and benefit of a particular treatment. Additional themes highlight the value placed on expertise in challenging clinical scenarios, the complexity of practice variation and the value placed on minimizing practice variation.

The Use of the Delphi and Other Consensus Group Methods in Medical Education Research: A Review.

PURPOSE: Consensus group methods, such as the Delphi method and nominal group technique (NGT), are used to synthesize expert opinions when evidence is lacking. Despite their extensive use, these methods are inconsistently applied. Their use in medical education research has not been well studied. The authors set out to describe the use of consensus methods in medical education research and to assess the reporting quality of these methods and results. METHOD: Using scoping review methods, the authors searched the Medline, Embase, PsycInfo, PubMed, Scopus, and ERIC databases for 2009-2016. Full-text articles that focused on medical education and the keywords Delphi, RAND, NGT, or other consensus group methods were included. A standardized extraction form was used to collect article demographic data and features reflecting methodological rigor. RESULTS: Of the articles reviewed, 257 met the inclusion criteria. The Modified Delphi (105/257; 40.8%), Delphi (91/257; 35.4%), and NGT (23/257; 8.9%) methods were most often used. The most common study purpose was curriculum development or reform (68/257; 26.5%), assessment tool development (55/257; 21.4%), and defining competencies (43/257; 16.7%). The reporting quality varied, with 70.0% (180/257) of articles reporting a literature review, 27.2% (70/257) reporting what background information was provided to participants, 66.1% (170/257) describing the number of participants, 40.1% (103/257) reporting if private decisions were collected, 37.7% (97/257) reporting if formal feedback of group ratings was shared, and 43.2% (111/257) defining consensus a priori. CONCLUSIONS: Consensus methods are poorly standardized and inconsistently used in medical education research. Improved criteria for reporting are needed.

Using consensus group methods such as Delphi and Nominal Group in medical education research.

Consensus group methods are widely used in research to identify and measure areas where incomplete evidence exists for decision-making. Despite their widespread use, these methods are often inconsistently used and reported. Using examples from the three most commonly used methods, the Delphi, Nominal Group and RAND/UCLA; this paper and associated Guide aim to describe these methods and to highlight common weaknesses in methodology and reporting. The paper outlines a series of recommendations to assist researchers using consensus group methods in providing a comprehensive description and justification of the steps taken in their study.

A novel approach to needs assessment in curriculum development: going beyond consensus methods.

BACKGROUND: Needs assessment should be the starting point for curriculum development. In medical education, expert opinion and consensus methods are commonly employed. AIM: This paper showcases a more practice-grounded needs assessment approach. METHODS: A mixed-methods approach, incorporating a national survey, practice audit, and expert consensus, was developed and piloted in thrombosis medicine; Phase 1: National survey of practicing consultants, Phase 2: Practice audit of consult service at a large academic centre and Phase 3: Focus group and modified Delphi techniques vetting Phase 1 and 2 findings. RESULTS: Phase 1 provided information on active curricula, training and practice patterns of consultants, and volume and variety of thrombosis consults. Phase 2's practice audit provided empirical data on the characteristics of thrombosis consults and their associated learning issues. Phase 3 generated consensus on a final curricular topic list and explored issues regarding curriculum delivery and accreditation. CONCLUSIONS: This approach offered a means of validating expert and consensus derived curricular content by incorporating a novel practice audit. By using this approach we were able to identify gaps in training programs and barriers to curriculum development. This approach to curriculum development can be applied to other postgraduate programs.

Effect of 200µG/day of vitamin K1 on the variability of anticoagulation control in patients on warfarin: a randomized controlled trial.

BACKGROUND: Controversy exists whether low-dose vitamin K supplementation can improve anticoagulation control in patients with unstable anticoagulation under warfarin. In a single- centre randomized, double-blind, placebo-controlled study, we evaluated the effectiveness of 200 µg/day of vitamin K1 in patients with unstable control under warfarin. METHODS: Effectiveness of Vitamin K1 supplementation was primarily assessed by the percentage (%) of Time-in-Therapeutic-Range (TTR) and secondarily by the standard deviation (SD) of the patient's INR values; the proportion of out-of-range INRs; and the number of dose changes on warfarin. Their change scores were obtained by subtracting the mean value in the 6 months pre-randomization from the mean value in the 6 months post-randomization. Multivariable linear-regressions identified factors associated with anticoagulation instability. RESULTS: Fifty out of 54 patients were analyzed (intervention: n=26; placebo: n=24). Most indications (87%) for anticoagulation were venous thromboembolism (VTE). The intervention was associated with a greater reduction in the change scores for the SD of INRs between the pre and post-randomization periods compared with placebo. The mean change score was -0.259±0.307 with the intervention and -0.046±0.345 with placebo (p=0.026). There was no effect on the change scores of the (%) TTR (p=0.98), the number of INRs out-of-range (p=0.58) and the number of dose changes (p=0.604). Factors independently associated with increased variability in the SD of INRs were increased alcoholic drinks/week (p=0.017), dosing errors (p=0.0009) and missed INR appointments (p=0.035). CONCLUSION: Vitamin K1 supplementation reduces the SD of INRs as an indicator of the variability in anticoagulation control in patients treated with warfarin for VTE.

Comparative development and impact of transgenic papayas in Hawaii, Jamaica, and Venezuela.

We present data concerning the creation of transgenic papayas resistant to Papaya ringspot virus (PRSV) and their adoption by three different countries: the United States (e.g., Hawaii), Jamaica, and Venezuela. Although the three sets of transgenic papayas showed effective resistance to PRSV, the adoption rate in each country has varied from full utilization in Hawaii to aggressive testing but delay in deregulating of the product in Jamaica to rejection at an early stage in Venezuela. Factors that contributed to the rapid adoption in Hawaii include a timely development of the transgenic product, PRSV causing severe damage to the papaya industry, close collaboration between researchers and the industry, and the existence of procedures for deregulating a transgenic product. In Jamaica, the technology for developing the initial field-testing of the product progressed rather rapidly, but the process of deregulation has been slowed down owing to the lack of sustained governmental efforts to complete the regulatory procedures for transgenic crops. In Venezuela, the technology to develop and greenhouse test the transgenic papaya has moved abreast with the Jamaica project, but the field testing of the transgenic papaya within the country was stopped very early on by actions by people opposed to transgenic products. The three cases are discussed in an effort to provide information on factors, other than technology, that can influence the adoption of a transgenic product.