A comparison of teaching opportunities for rural and urban family medicine residents.

CONTEXT: Medical schools of geographically large nations have expanded into rural areas to facilitate the development of a sustainable rural pipeline of physicians. Preceptor, or clinical teacher, recruitment at these sites has been an ongoing challenge. However, residents-as-teachers (RaT) curricula have not been modified to support the development of rural teachers. This study aimed to compare teaching opportunities between rural and urban family medicine residents and to identify mechanisms underlying potential differences. METHODS: Year-1 and Year-2 family medicine residents at seven Canadian institutions participated in a mixed-methods study utilising a quantitative survey and a qualitative interview. Rural and urban residents rated the quantity and types of teaching opportunities available during their training, from which a chi-squared analysis was completed. Volunteer respondents participated in a structured interview, from which a thematic analysis was performed. RESULTS: Rural family medicine residents had fewer opportunities to teach compared to their urban colleagues. This discrepancy was seen across multiple domains, including informal opportunities when on family medicine rotations, χ2 (4, n = 242) = 45.26, P < .000, Bonferroni's adjusted P < .000. Thematic analysis centred around determining factors influencing teaching opportunities and identified that the academic context, personal factors and programme factors were key dimensions. Within these dimensions, the number of medical students, a desire to be an educator and administrative support were cited as influences on teaching opportunities. CONCLUSIONS: The lack of teaching opportunities for rural trainees is attributable to a combination of practical and organisational factors revealed through thematic analysis. If rural graduates are not comfortable balancing the demands of service and teaching, this could compound the already prevalent issue of rural preceptor recruitment. It is essential to develop a rural-focused RaT curriculum to close this gap and produce competent educators who are ready to inspire generations of rural physicians.

The Odds Ratio Product (An Objective Sleep Depth Measure): Normal Values, Repeatability, and Change With CPAP in Patients With OSA.

STUDY OBJECTIVES: The Odds Ratio Product (ORP) is an objective measure of sleep depth using the relationships of the powers of different electroencephalogram (EEG) frequencies in a single index. The range of the ORP is 0 (deeply asleep) to 2.5 (fully awake). This investigation seeks to elucidate normal values of non-rapid eye movement ORP (ORPNR) in healthy individuals, repeatability of the measure, and the change in ORPNR following continuous positive airway pressure (CPAP) treatment. METHODS: Healthy individuals underwent a home sleep apnea test (HSAT) with EEG followed 1 week later by EEG alone. Another cohort with OSA underwent baseline HSAT with EEG followed by a second EEG study approximately 4 weeks into treatment with CPAP. RESULTS: Thirty-eight healthy individuals completed the protocol (mean age of 34.9 ± 7.4 years, Epworth Sleepiness Scale score 3.6 ± 2.4, Insomnia Severity Index score 2.0 ± 1.6 and Functional Outcomes of Sleep Questionnaire - shorter version score 19 ± 1.2). The mean ORPNR for all nights was 0.52 ± 0.13. The difference between the first night and the second night was 0.024 ± 0.17 (not significant). The intraclass correlation coefficient was 0.525, suggesting only moderate agreement between the first and second nights. The normal value for ORPNR in healthy individuals is ≤ 0.78 units using two standard deviations as the cutoff. Forty participants completed the OSA protocol (mean age 49 ± 11 years, body mass index 35 ± 6 kg/m², apnea-hypopnea index 33.5 ± 28.4 events/h). The mean pre-CPAP ORPNR was 0.69 ± 0.24 and the mean post-CPAP ORPNR was 0.57 ± 0.22 (P = .02). CONCLUSIONS: The ORPNR proves to have significant variability from night to night in healthy individuals. ORPNR objectively improves following CPAP treatment, providing further evidence that it measures sleep depth. CITATION: Penner CG, Gerardy B, Ryan R, Williams M. The odds ratio product (an objective sleep depth measure): normal values, repeatability, and change with CPAP in patients with OSA. J Clin Sleep Med. 2019;15(8):1155-1163.

Trajectories of physicians in Manitoba, Canada: the influence of contact points of rural-focused professional learning.

BACKGROUND: The Manitoba Office of Rural and Northern Health (ORNH) provided a multi-year series of elective opportunities for undergraduate medical students to support rural/remote medical practice. The purpose of this study was to examine the career trajectories of Manitoba physicians in eight matched cohorts over the period 2004-2007 between: 1) those who experienced a required rural clinical block rotation only during their undergraduate medicine training in Manitoba (Med 1 and Med 3), and; 2) those who engaged in and completed additional elective programs referred to here as "contact points". METHODS: The study utilized a retrospective/longitudinal matched cohort design which included the common factor of a mandated rural clinical one-week rotation and the differentiating factors of experiences in elective programming offered by the ORNH (contact points). RESULTS: Of the 344 Manitoba-trained physicians whose location of current practice could be determined, 74 are presently in rural/remote communities and 270 in urban settings. Those physicians who are now in rural/remote practice were significantly more likely (p ≤ 0.05) to have continued contact with ORNH in addition to the mandatory rural rotation alone. For practitioners now located in rural/remote settings, a mean of 0.903 contact points per learner with ORNH programs is observed. For those now in urban practice the mean number of contact points per learner was 0.233. CONCLUSION: We conclude that there is an association between rural-focused contact points and rural and remote practice in Manitoba. Targeted professional learning where physician recruitment and retention remains a continuing challenge is discussed.

Are rural residents missing out on teaching? A comparison of teaching opportunities for urban and rural family medicine residents at the University of Manitoba.

BACKGROUND: The scholar competency of the CanMEDS-FM framework requires residents to develop teaching skills, and with the number of rural residency positions tripling over the last decade, it is essential for residency programs to provide rural residents with teaching opportunities. The purpose of this study was to investigate the differences in teaching opportunities offered to urban and rural family medicine residents at the University of Manitoba. METHODS: The 117 urban and rural family medicine residents were surveyed to quantify their interactions with medical students. Specific respondents were interviewed to provide context to the survey. RESULTS: On family medicine, only 20% of rural residents reported frequent opportunities to informally teach, compared to 57% of urban residents. Similarly, 86% of urban residents reported organized teaching opportunities compared to only 5% of rural residents. Residents placed high value in receiving additional teaching opportunities. CONCLUSION: This study suggests that there are fewer teaching opportunities for rural family medicine residents compared to urban residents at the University of Manitoba. Given the small sample size, a larger study could determine whether this trend exists across the country. It will be incumbent on residency programs to ensure rural residents have the opportunities to become competent educators.

A tale of two campuses: Lessons learned in establishing a satellite campus.

"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity." The opening line of Dickens's A Tale of Two Cities could easily be the dramatic opening line of a summary of the establishment of a satellite medical school campus in Manitoba. Reflection on my last four years as associate dean reveals that most of the descriptors in that famous sentence at one time or another were apropos. This brief essay will relate the experiences of the last four years and some of the lessons learned along the way.

Activated protein C and septic shock: a propensity-matched cohort study*.

BACKGROUND: Septic shock is a highly inflammatory and procoagulant state associated with significant mortality. In a single randomized controlled trial, recombinant human activated protein C (drotrecogin alfa) reduced mortality in patients with severe sepsis at high risk of death. Further clinical trials, including a recently completed trial in patients with septic shock, failed to reproduce these results. OBJECTIVE: To evaluate the effectiveness of recombinant human activated protein C on mortality in a cohort of patients with septic shock and to explore possible reasons for inconsistent results in previous studies. DESIGN: Retrospective, 2:1 propensity-matched, multicenter cohort study. SETTING: Twenty-nine academic and community intensive care units in three countries. PATIENTS: Seven thousand three hundred ninety-two adult patients diagnosed with septic shock, of which 349 received recombinant human activated protein C within 48 hrs of intensive care unit admission between 1997 and 2007. MEASUREMENTS AND MAIN RESULTS: Our primary outcomes were mortality over 30 days and mortality stratified by Acute Physiology and Chronic Health Evaluation II quartile. Using a propensity-matched Cox proportional hazard model, we observed a 6.1% absolute reduction in 30-day mortality associated with the use of recombinant human activated protein C (108/311 [34.7%] vs. 254/622 [40.8%], hazard ratio 0.72, 95% confidence interval 0.52-1.00, p = .05) and noted consistent reductions in mortality among Acute Physiology and Chronic Health Evaluation II quartiles. A time to event analysis showed that the time to appropriate antimicrobials after documented hypotension decreased for each year of study (p = .003), a finding that was congruent with a decrease in annual mortality over the study period (odds ratio 0.96 per year [95% confidence interval 0.93-0.99], p = .003). CONCLUSIONS: In this retrospective, propensity-matched, multicenter cohort study of patients with septic shock, early use of recombinant human activated protein C was associated with reduced mortality. Improvements in general quality of care such as speed of antimicrobial delivery leading to decreasing mortality of patients with septic shock may have contributed to the null results of the recently completed trial of recombinant human activated protein C in patients with septic shock.

Hereditary angioedema managed with low-dose danazol and C1 esterase inhibitor concentrate: a case report.

BACKGROUND: Hereditary angioedema (HAE) is a rare life-threatening disease that can occur in pregnancy. CASE: A nulliparous woman was diagnosed as having HAE at 22 weeks of gestation after a series of symptomatic episodes. Following an initial course of C1 esterase inhibitor (C1EI) therapy for an acute episode of HAE, she was treated with danazol for prophylaxis. Danazol did not prevent recurrence of symptoms, its use was discontinued after six weeks. Thereafter, the patient was treated exclusively with C1EI at weekly intervals for exacerbations of her HAE. At 37 weeks' gestation, she delivered healthy 3050 g female neonate. At the time of discharge the female neonate had no signs of virilization or congenital anomalies. CONCLUSION: Low dose danazol was ineffective in treating this woman's HAE in pregnancy. The use of C1EI in pregnancy is associated with good outcomes.