New beginnings in post graduate medical education. Latin American Medical Education Leaders Forum / Nuevos comienzos en la educación médica de postgrado. Foro Latinoamericano de Líderes en Educación Médica

Introduction: The consequences of the Covid-19 epidemic have been catastrophic for Latin America in 2021. This study explores experiences, lessons learned, and practice changes during this critical time in post-graduate medical education in Latin America. Me-thods: A panel of 53 post-graduate medical education leaders from 8 Latin American countries and Canada was invited to participate in the 2021 Latin American Medical Education Leaders Forum to share their experiences, lessons learned, and main educational practice changes given the Covid-19 pandemic scenario. Participants were selected following a snowball technique with the goal of obtaining a diverse group of experts. Small group discussions were conducted by bilingual facilitators based on a semi-structured questionnaire. The plenary session with the main conclusions of each group was recorded and fully transcribed for a thematic analysis using a framework methods approach. Results: Participants ́ profiles included 13 experienced clinician-educators, 19 program directors, and 23 deans or organizational representatives. Seven specific themes emerged. They followed a pattern that went from an initial emotional reaction of surprise to a complex collective response. The responses highlighted the value of adaptability, the application of new digital skills, a renovated residents' protagonism, the strengthening of humanism in medicine, the openness of new perspectives in wellness, and finally, an unresolved challenge of assessment in medical education in a virtual post-pandemic scenario. Conclusion: A diverse panel of medical educators from Latin America and Canada identified changes triggered by the Covid-19 pandemic that could transform postgraduate medical education in the region.

Introducción: la pandemia de Covid-19 ha tenido consecuencias catastróficas para América Latina en el año 2021. Este estudio explora las experiencias, lecciones aprendidas y nuevas prácticas surgidas durante este crítico período en la educación médica de postgrado en América Latina. Métodos: un panel de 53 líderes de 8 países de América Latina y Canadá fue invitado a participar en el Foro Latinoame-ricano de Líderes en Educación Médica 2021 para compartir sus experiencias, lecciones aprendidas y cambios de prácticas educativas en el escenario de pandemia. Los participantes fueron seleccionados mediante la técnica de bola de nieve con el objetivo de obtener un grupo diverso de expertos. El Foro incluyó discusiones de pequeños grupos conducidos por facilitadores bilingües basadas en un cuestionario semiestructurado. La sesión plenaria con las principales conclusiones de los grupos fue grabada y transcrita para el análisis temático posterior utilizando la metodología de marco analítico. Resultados: el perfil de participantes incluyó 13 experimentados edu-cadores, 19 directores de programa y 23 decanos o representantes institucionales. Siete tópicos emergieron durante la discusión. Ellos siguieron un patrón que transitó desde una reacción emocional de sorpresa por la pandemia hasta una respuesta colectiva compleja. Las respuestas enfatizaron el valor de la adaptabilidad, la aplicación de nuevas habilidades digitales, un renovado protagonismo de los residentes, el fortalecimiento del humanismo en medicina, la apertura a nuevas perspectivas de bienestar y, finalmente, un desafío no resuelto respecto de la evaluación en educación médica en escenarios de pandemia. Conclusión: un panel diverso de educadores médicos latinoamericanos y canadienses identificó cambios claves gatillados por la pandemia de Covid-19 que pueden transformar la educación médica de postgrado en la región.

Burnout en médicos residentes de especialidades y subespecialidades: estudio de prevalencia y variables asociadas en un centro universitario / Burnout in resident doctors of specialties and subspecialties: study of prevalence and associated variables in a university center

Introducción: El burnout es un síndrome caracterizado por agotamiento emocional, despersonalización y bajo sentido de logro personal. Los médicos residentes de especialidad y subespecialidad constituyen una población de riesgo por la alta carga laboral y la interferencia con su vida personal. Nuestro objetivo fue evaluar la prevalencia de burnout y su asociación con variables sociodemográficas, en residentes de especialidad y subespecialidad de la Pontificia Universidad Católica de Chile (PUC). Métodos: Se realizó una encuesta electrónica a los residentes de especialidad y subespecialidad de la PUC, que incluyó el "Inventario de Burnout de Maslach" (22 preguntas divididas en 3 dimensiones). Se sumaron los puntos de cada dimensión y se clasificó a los residentes en riesgo de burnout al presentar altos índices de agotamiento emocional y/o despersonalización. El análisis estadístico incluyó un análisis univariado y multivariado. Resultados: 415 encuestas fueron contestadas (tasa de respuesta 86 por ciento). El 38,3 por ciento de los residentes cumplió criterios de burnout, con un 41,9 por ciento en residentes de especialidad y 24,1por ciento en residentes de subespecialidad. En el análisis por subgrupos, la mayor prevalencia se encontró en especialidades quirúrgicas (55,3por ciento). Los residentes extranjeros, los programas de especialidad (comparados con subespecialidad) y los programas de especialidades quirúrgicas se asociaron de manera independiente a burnout (OR 3,8 IC95 por ciento 1,4-10,5, p=0,01; OR 2,3 IC95 por ciento 1,3-4,1, p<0,01 y OR 1,7 IC95 por ciento 1,1-2,7; p=0,02, respectivamente). La carga laboral horaria no se asoció de manera independiente a burnout (p=0,19). Conclusión: Los residentes de especialidad y subespecialidad presentan una alta prevalencia de burnout. Adicionalmente, ser extranjero, el pertenecer a un programa de especialidad y los programas de especialidades quirúrgicas se asocian de manera independiente a burnout.(AU)

Introduction: Burnoutis a pathological syndrome characterized by emotional exhaustion, depersonalization and low sense of personal accomplishment. Residents from medical specialties and subspecialties constitute a population at risk for high work overload and interference in personal life. The aim of this study was to evaluate the prevalence of burnout and its associations with sociodemographic variables, in specialty and subspecialty residents of the Pontificia Universidad Católica de Chile (PUC). Methods: An electronic survey was answered by residents of specialty and subspecialty of PUC. It included the "Maslach Burnout Inventory" (which consists of 22 questions divided into 3 dimensions). The points of each dimension were added and burnout was defined as a high score on depersonalization or emotional exhaustion subscales. Statistical analysis included an univariate and multivariate analysis. Results: 415 surveys were answered (response rate 86 percent). 38.3 percent of residents met criteria for burnout, with a percentage of 41.9 percent for specialty residents and 24.1 percent for subspecialty residents. In the subgroup analysis, the highest prevalence was found in surgical specialties (55.3 percent). Foreign residents, medical residency programs (compared to sub specialization programs) and surgical programs were independently associated with burnout (OR 3.8 IC95 percent1.4-10.5, p=0.01; OR 2.3 IC95 percent 1.3-4.1, p<0.01 y OR 1.7 IC95% 1.1-2.7; p=0.02, respectively). There was no independent association between duty hours and burnout (p=0.19). Conclusion: Specialty and subspecialty residents have a high prevalence of burnout. Additionally, foreign residents, participation in a speciality residency (compared to subspecialties programs) and surgical residencies are independently associated to burnout. (AU)

[Inappropriate medication use among Chilean older people]. / Uso inapropiado de medicamentos en adultos mayores: resultados de la Encuesta Nacional de Salud 2010.

BACKGROUND: Inappropriate medication use in older people is an important source of adverse events and complications. AIM: To determine the frequency of inappropriate medication use in the general population. MATERIAL AND METHODS: As part of the 2010 Chilean National Health Survey, 1,048 persons aged 65 years or more were interviewed about medication use. The information obtained was analyzed using standardized Beer’s criteria, adapted for the Chilean population, to define inappropriate medication use. A logistic regression model was performed to define risk factors for inappropriate medication use. RESULTS: Ten percent of subjects had a high risk of inappropriate medication use. The most common medications used were chlorphenamine, amitriptyline, diazepam, chlorpromazine, chlordiazepoxide and piroxicam. The risk factors detected were female gender, polypharmacy and a bad health self-perception. CONCLUSIONS: Inappropriate medication use is common among Chilean older people and should be discouraged.

Uso inapropiado de medicamentos en adultos mayores: resultados de la Encuesta Nacional de Salud 2010 / Inappropriate medication use among Chilean older people

Background: Inappropriate medication use in older people is an important source of adverse events and complications. Aim: To determine the frequency of inappropriate medication use in the general population. Material and Methods: As part of the 2010 Chilean National Health Survey, 1,048 persons aged 65 years or more were interviewed about medication use. The information obtained was analyzed using standardized Beer’s criteria, adapted for the Chilean population, to define inappropriate medication use. A logistic regression model was performed to define risk factors for inappropriate medication use. Results: Ten percent of subjects had a high risk of inappropriate medication use. The most common medications used were chlorphenamine, amitriptyline, diazepam, chlorpromazine, chlordiazepoxide and piroxicam. The risk factors detected were female gender, polypharmacy and a bad health self-perception. Conclusions: Inappropriate medication use is common among Chilean older people and should be discouraged.

Evaluación de la carga laboral en residentes Chilenos de especialidades y subespecialidades médicas / Workload assessment in Chilean residents of specialties and medical subspecialties

Introducción: La sobrecarga laboral horaria es un importante problema en los programas de especialización médica. Se asocia a mayor prevalencia de depresión, burnout, deserción, e impacta en la calidad de vida de los residentes. Nuestro objetivo fue cuantificar las horas semanales de carga laboral horaria en residentes de especialidad y subespecialidad de la Pontificia Universidad Católica de Chile (PUC). Métodos: Se realizó una encuesta electrónica a los residentes de especialidad y subespecialidad de la Pontificia Universidad Católica de Chile (2013). Esta incluyó autorreporte de horas semanales trabajadas (jornada habitual, turnos presenciales y turnos de llamada). Para el análisis se consideraron solo las horas presenciales (jornada habitual y turnos presenciales Resultados: se obtuvieron 415 respuestas (tasa de respuesta 86%). Los residentes de especialidad reportaron una jornada de 52,8 ± 20,3 horas semanales más un promedio de 22,6 ± 22,5 horas de turnos presenciales semanales. Los residentes de programas de subespecialidad reportaron una jornada de 55,9 ± 22,2 horas semanales más un promedio de 23 ± 3,9 horas de turnos presenciales semanales. De los 53 programas evaluados, el 22,6 por ciento sobrepasó el límite recomendado por la Dirección de Postgrado PUC (80 horas semanales). Cinco programas reportaron 90-100 horas semanales (todas especialidades o subespecialidades quirúrgicas) y 7 programas reportaron 80-90 horas semanales (3 subespecialidades médicas, 1 subespecialidad quirúrgica, 2 especialidades médicas y 1 especialidad quirúrgica). Conclusión: los residentes de especialidades y subespecialidades médicas en la Pontificia Universidad Católica de Chile están sometidos a una carga horaria significativa. Los programas quirúrgicos presentaron la mayor sobrecarga horaria presencial, con un promedio mayor al recomendado a nivel internacional. (AU)

Introduction: Residents work hours' overload constitutes an important problem in medical postgraduate residency programs. It has been associated to an increased prevalence of depression, burnout, attrition and affects quality of life of residents. The aim of our study was to quantify the duty hours in residents of specialty and subspecialty at the Pontificia Universidad Católica de Chile (PUC). Methods: An electronic survey was performed to residents of specialty and subspecialty at PUC (2013). It included an auto report of the duty hours worked in a week (regular working day, night shifts and on call shifts). We only included for analysis the face hours (regular working day and night shifts). Results: 415 surveys were answered (response rate 86percent). Specialty residents reported 52.8 ± 20.3 regular working hours per week plus an average of 22.6 ± 22.5 hours of night shifts. Subspecialty residents reported 55.9 ± 22.2 regular working hours per week plus an average of 23 ± 3.9 hours of night shifts. From the 53 evaluated programs, 22.6 percent exceeded the limit recommended in the PUC Postgraduate Office (80 hours per week). Five programs reported 90-100 hours per week (all were surgical specialties and subspecialties) and 7 programs reported 80-90 hours per week (3 medical subspecialties, 1 surgical subspecialty, 2 medical specialties and 1 surgical specialty). Conclusion: The residents of specialty and subspecialty from medical postgraduate programs at PUC are subject to a significant workload. The surgical programs present the highest time workload, with a greater average than the internationally recommended.(AU)

[Development of MEDUC-PG14 survey to assess postgraduate teaching in medical specialties]. / Evaluación de docentes clínicos de Postgrado: desarrollo y propiedades psicométricas del instrumento MEDUC-PG14.

BACKGROUND: Feedback is one of the most important tools to improve teaching in medical education. AIM: To develop an instrument to assess the performance of clinical postgraduate teachers in medical specialties. MATERIAL AND METHODS: A qualitative methodology consisting in interviews and focus-groups followed by a quantitative methodology to generate consensus, was employed. After generating the instrument, psychometric tests were performed to assess the construct validity (factor analysis) and reliability (Cronbach’s alpha). RESULTS: Experts in medical education, teachers and residents of a medical school participated in interviews and focus groups. With this information, 26 categories (79 items) were proposed and reduced to 14 items (Likert scale 1-5) by an expert’s Delphi panel, generating the MEDUC-PG14 survey, which was answered by 123 residents from different programs of medical specialties. Construct validity was carried out. Factor analysis showed three domains: Teaching and evaluation, respectful behavior towards patients and health care team, and providing feedback. The global score was 4.46 ± 0.94 (89% of the maximum). One teachers’ strength, as evaluated by their residents was “respectful behavior” with 4.85 ± 0.42 (97% of the maximum). “Providing feedback” obtained 4.09 ± 1.0 points (81.8% of the maximum). MEDUC-PG14 survey had a Cronbach’s alpha coefficient of 0.947. CONCLUSIONS: MEDUC-PG14 survey is a useful and reliable guide for teacher evaluation in medical specialty programs. Also provides feedback to improve educational skills of postgraduate clinical teachers.

Evaluación de docentes clínicos de Postgrado: desarrollo y propiedades psicométricas del instrumento MEDUC-PG14 / Development of MEDUC-PG14 survey to assess postgraduate teaching in medical specialties

Background: Feedback is one of the most important tools to improve teaching in medical education. Aim: To develop an instrument to assess the performance of clinical postgraduate teachers in medical specialties. Material and Methods: A qualitative methodology consisting in interviews and focus-groups followed by a quantitative methodology to generate consensus, was employed. After generating the instrument, psychometric tests were performed to assess the construct validity (factor analysis) and reliability (Cronbach’s alpha). Results: Experts in medical education, teachers and residents of a medical school participated in interviews and focus groups. With this information, 26 categories (79 items) were proposed and reduced to 14 items (Likert scale 1-5) by an expert’s Delphi panel, generating the MEDUC-PG14 survey, which was answered by 123 residents from different programs of medical specialties. Construct validity was carried out. Factor analysis showed three domains: Teaching and evaluation, respectful behavior towards patients and health care team, and providing feedback. The global score was 4.46 ± 0.94 (89% of the maximum). One teachers’ strength, as evaluated by their residents was “respectful behavior” with 4.85 ± 0.42 (97% of the maximum). “Providing feedback” obtained 4.09 ± 1.0 points (81.8% of the maximum). MEDUC-PG14 survey had a Cronbach’s alpha coefficient of 0.947. Conclusions: MEDUC-PG14 survey is a useful and reliable guide for teacher evaluation in medical specialty programs. Also provides feedback to improve educational skills of postgraduate clinical teachers.

Identificación y caracterización del adulto mayor saludable / A novel method for targeting and characterizing healthy older people

Background: There is no established definition of healthy aging in clinical practice, although it is a World Health Organization goal. Aim: To develop a clinical protocol to identify healthy older people living in the community and study their clinical, laboratory and functional characteristics. Material and Methods: Healthy people aged 60 years or older, were invited to participate in the study, by newspapers and radio, if they selfperceived as healthy, lived in the community, were functionally independent and had low disease burden. Potential participants were initially screened by telephone, and those who met the inclusion criteria were included. They had a comprehensive geriatric assessment which included clinical, anthropometric, laboratory and functional assessments. Results: Of 384 people who answered the call, 83 subjects aged 60 to 98 years (57 percent women) met the inclusion criteria of healthy older people. Seventy eight percent did not consume any medication, 100 percent were able to perform physical activities that required at least three metabolic equivalents (Mets). Basic laboratory showed that approximately 90 percent of subjects had normal values, using standard benchmarks established for an adult population. Conclusions: The protocol used in this work was able to identify healthy older people with low disease burden and good functionality. It also validated history and comprehensive geriatric assessment as reliable instruments to identify these subjects.

[A novel method for targeting and characterizing healthy older people]. / Identificación y caracterización del adulto mayor saludable.

BACKGROUND: there is no established definition of healthy aging in clinical practice, although it is a World Health Organization goal. AIM: to develop a clinical protocol to identify healthy older people living in the community and study their clinical, laboratory and functional characteristics. MATERIAL AND METHODS: healthy people aged 60 years or older, were invited to participate in the study, by newspapers and radio, if they selfperceived as healthy, lived in the community, were functionally independent and had low disease burden. Potential participants were initially screened by telephone, and those who met the inclusion criteria were included. They had a comprehensive geriatric assessment which included clinical, anthropometric, laboratory and functional assessments. RESULTS: of 384 people who answered the call, 83 subjects aged 60 to 98 years (57% women) met the inclusion criteria of healthy older people. Seventy eight percent did not consume any medication, 100% were able to perform physical activities that required at least three metabolic equivalents (Mets). Basic laboratory showed that approximately 90% of subjects had normal values, using standard benchmarks established for an adult population. CONCLUSIONS: the protocol used in this work was able to identify healthy older people with low disease burden and good functionality. It also validated history and comprehensive geriatric assessment as reliable instruments to identify these subjects.

[Delirium in Chilean elderly inpatients: an overlooked problem]. / Subdiagnóstico de delirium en adultos mayores hospitalizados.

BACKGROUND: Delirium is a common underdiagnosed and undertreated problem in elderly inpatients, associated to higher morbidity, mortality and health cost. AIM: To evaluate the prevalence of delirium at hospital admission in medically ill elderly patients and the attending physician's diagnosis and treatment of delirium. PATIENTS AND METHODS: In a prospective and descriptive study, consecutive patients aged 65 years or more, admitted to an internal medicine ward were evaluated by independent physicians, during the first 48 h of admission, to asses the presence of delirium. Diagnosis of delirium was based on the Confusion Assessment Method. Medical and nurse records were reviewed. Family was interviewed when necessary. RESULTS: One hundred eight patients (52% women, age range 65-94 years) with an APACHE II score of 11.6+/-5, were evaluated. Fifty seven patients (53%) had delirium (32% hyperactive, 72% hypoactive and 5% mixed). Delirium prevalence was significantly higher in older patients (66% among those aged 75 years or older versus 30% in younger, p <0.05) and among patients with more severe conditions (88% among those with an APACHE score over 16 versus 47% below that value, p <0.05). Medical records of patients with delirium showed that this diagnosis was present only in 32% and cognitive deficit was described in 73%. Ten percent of patients with delirium received sedative medication and 38% were physically restricted. There were no environmental interventions to prevent or control delirium. CONCLUSIONS: Delirium in elderly inpatients at this unit is an extraordinarily prevalent problem, seriously under diagnosed (68%) and under treated. This study should alerts our medical community to improve the diagnosis and management of delirium in elderly inpatients.

[A comparative study of institutionalized nonagenarian and younger elderly women]. / Estudio comparativo de mujeres mayores de noventa años y ancianas menores institucionalizadas.

BACKGROUND: The number of nonagenarians is rapidly growing in Chile. This age group is mainly female, with higher frailty markers and in higher risk of being placed at nursing homes. AIM: To describe features of nonagenarian women and compare them with a group of women between 60-89 years, both living in nursing homes, in terms of disability and resource use at the institution. SUBJECTS AND METHODS: A total of 230 nonagenarian women and 460 women, aged 60-89 years, were evaluated in the nursing home Fundación Las Rosas de Ayuda Fraterna (only for poor elderly) in Santiago, Chile. The assessment instruments were the Geriatric Assessment instrument FEGAUC, functional and mental evaluation scales of Spanish Red Cross and the Resource Utilization System, RUG T18, an independent diagnostic classification system that allows the determination of resource use in terms of cost and personnel needs. RESULTS: Nonagenarian women had significantly (p <0.05) more disability (falls, urinary incontinence, memory problems and mobility difficulties), and were classified in RUG categories of higher resource utilization and dependency than younger women. Nevertheless, nonagenarians were a very heterogeneous group, almost half of them were able of moving by themselves or required little assistance and had minimal memory problems. CONCLUSIONS: Nonagenarian women assessed in this institution are an heterogeneous group, some with minimal disability and other more frail and dependent than the younger elderly women, being classified in higher categories of resource utilization RUG T18.

[Assessment of 1497 Chilean nursing home residents, using the Resource Utilization Group method, RUG T-18]. / Evaluación de 1,497 adultos mayores institucionalizados, usando el "sistema de clasificación de pacientes RUG T-18".

BACKGROUND: There is little information about Chilean elderly residents of long term care facilities, regarding their characteristics and need for resources. AIM: To describe main characteristics and resource utilization of residents of one of the largest nursing homes in Chile, Fundación Las Rosas de Ayuda Fraterna. MATERIAL AND METHODS: In a cross sectional and descriptive study, all residents were evaluated using the RUG T-18 method, that assess activities of daily living and the complexity of their clinical situation. RESULTS: We assessed 1497 subjects 60 years old and over (73% women), with an age range of 60-106 years. Thirty six percent had urinary incontinence, 19% required assistance for feeding, and 38% needed help for walking or moving. Fifty seven percent were in the lowest category of complexity, "Institutionalization". Very few residents were in the most demanding categories, no one classified as "Rehabilitation", and only 0.7% were in "Special Care". CONCLUSIONS: This study is an important start point to learn more about elderly subjects living in nursing homes in Chile.

[Biomedical impact of traveling for Chilean elderly]. / Impacto biomédico de los viajes en adultos mayores chilenos.

BACKGROUND: In Chile there is a program named "Vacations for Elderly during Low Season". AIM: To characterize participants of this program and to measure the impact of traveling in their health and wellbeing. MATERIAL AND METHODS: Two anonymous and voluntary questionnaires were applied to 4200 participants, before and after a ten days vacation package. RESULTS: Before traveling, questionnaires were answered by 802 subjects, and after traveling by 4057 (69% women, 22% older than 75 years old, 15.8% living alone). The presence and maintaining of good health were most appreciated at this age and 59% classified their health as good or excellent. Twenty five percent referred sensory problems (seeing or hearing), 12% reported urinary incontinence and 21% presented falls in the last three months; depression screening (GDS-5) was positive in 16%. Chronic disease prevalence was similar to the general Chilean elderly population. After traveling they reported significant improvements in the items sociability, wellbeing, mood, appetite, insomnia and ostheoarthritic pain. CONCLUSIONS: Elderly who traveled were mainly women, who thought that maintaining good health is the most precious value. After traveling they improved significantly different aspects of wellbeing. Promotion of this kind of recreation programs is an important tool for integration and enhancement of quality of life in elderly subjects in our country.

[Falls in institutionalized elderly subjects. Features and geriatric assessment]. / Caídas en adultos mayores institucionalizados: descripción y evaluación geriátrica.

BACKGROUND: Falls are an important cause of disability and mortality among elderly subjects. AIM: To study the features and incidence of falls in institutionalized elderly subjects. PATIENTS AND METHODS: Prospective recording of all falls, occurring in a period of eight months, to 453 subjects older than 60 years, living a home for the elderly. Evaluation of functional status of subjects suffering falls, using the Spanish Red Cross score. One hundred and two subjects living in the same place, but not suffering falls, were considered as controls. RESULTS: One hundred and three subjects, aged 80 +/- 6 years (24% of the sample) suffered falls. Most falls were during the day and while walking. Seventy percent of subjects suffering falls did not have a history of previous falls. Nine percent of those falling, suffered a fracture. Compared to controls, falling subjects had a more deteriorated functional and mental status and consumed more benzodiazepines and neuroleptics. CONCLUSIONS: There is an association between functional status and psychotropic medication consumption and the incidence of falls in institutionalized elderly subjects.