Learning Health Systems: A Paradigm Shift in What We Can Do about Digital Health Inequities.

Learning health systems (LHSs) embed social accountability into everyday workflows and can inform how governments build bridges across the digital health divide. They shape partnerships using rapid cycles of data-driven learning to respond to patients' calls to action for equity from digital health. Adopting the LHS approach involves re-distributing power, which is likely to be met with resistance. We use the LHS example of British Columbia's 811 services to highlight how infrastructure was created to provide care and answer questions about access to digital health, outcomes from it and the financial impact passed on to patients. In the concluding section, we offer an accountability framework that facilitates partnerships in making digital health more equitable.

Evaluation of Mechanical Properties of Various Nanofibre Reinforced Bis-GMA/TEGDMA Based Dental Composite Resins / Evaluación de las propiedades mecánicas de varias resinas compuestas dentales basadas en Bis-GMA/TEGDMA reforzadas con nanofibras

ABSTRACT Objective: To investigate the mechanical properties of various mass fractions of Nylon 6 (N6), polymethyl-metacrylate (PMMA) and polyvinylidene-difluoride (PVDF) nanofibres reinforced bisphenol A-glycidyl methacrylate (Bis-GMA) and tri-ethylene glycol dimethacrylate (TEGDMA) based dental composite resins and to evaluate the penetration characteristics of the nanofibres into the resin. Methods: Nylon 6, PMMA and PVDF nanofibres were produced using the electrospinning method. The morphologies of the fabricated nanofibres were evaluated with a scanning electron microscope (SEM). The nanofibres were placed into the resin matrix at different mass fractions (3%, 5% and 7%). The three-point bending test was applied to nanofibre-reinforced dental composite resins and neat resin specimens. The flexural strength (Fs), flexural modulus (EY) and work of fracture (WOF) of the groups were found. The analysis of variance was used for the statistical analysis of the acquired data. Tukey 's multiple test was performed to compare the Fs, EY and WOF means. Fractured surfaces of the samples were observed by SEM, and fracture morphologies were evaluated. Results: Polymethyl-metacrylate nanofibres dissolved in the matrix, and a polymer alloy took place in the matrix. Fibre pull-out and fibre bridging mechanisms were observed by SEM images of the N6 and PVDF nanofibre-reinforced dental composites. The produced nanofibres enhanced the mechanical properties of the dental composite resins. Conclusion: Fibre pull-out and fibre bridging mechanisms on the fractured surfaces of samples may play a key role in the reinforcement of dental composite resins. However, polymer alloy of PMMA nanofibres increased the mechanical properties of the resin matrix.

RESUMEN Objetivo: Investigar las propiedades mecánicas de resinas compuestas dentales basadas en bisfenol A-diglicidildimetacrilato (Bis-GMA) y dimetacrilato trietilen-glicol (TEGDMA) reforzadas con nanofibras de fracciones de masa de Nylon 6 (N6), polimetilmetacrilato (PMMA) y fluoruro de polivinilideno (PVDF), y evaluar las características de la penetración de las nanofibras en la resina. Métodos: Se produjeron nanofibras de Nylon 6, PMMA y PVDF utilizando el método de electrohilado (electrospinning). Las morfologías de las nanofibras fabricadas fueron evaluadas con un microscopio electrónico de barrido (MEB). Las nanofibras fueron introducidas en la matriz de resina en diferentes fracciones de masa (3%, 5% y 7%). La prueba de flexión de tres puntos fue aplicada a las resinas compuestas dentales reforzadas por nanofibras y a las muestras de resina pura. La resistencia a la flexión (Rf), el módulo de flexión (EY) y el trabajo de fractura (WOF) de los grupos fueron halladas. El análisis de varianza se usó para el análisis estadístico de los datos adquiridos. Se realizó la prueba de comparaciones múltiples de Tukey con el propósito de comparar las medidas de Rf, EY y WOF. Las superficies fracturadas de las muestras fueron observadas mediante un MEB, y se evaluaron las morfologías de fractura. Resultados: Las nanofibras de polimetilmetacrilato se disolvieron en la matriz, y tuvo lugar una aleación de polímeros en la matriz. Los mecanismos de desprendimiento de fibras y puenteo de fibras fueron observados mediante imágenes de MEB de los compuestos dentales reforzados con nanofibras de N6 y PVDF. Las nanofibras producidas realzaron las propiedades mecánicas de las resinas compuestas dentales. Conclusión: Los mecanismos de desprendimiento de fibras y puenteo de fibras en las superficies fracturadas de las muestras pueden desempeñar un papel clave en el reforzamiento de las resinas de los compuestos dentales. Sin embargo, la aleación polimérica de las nanofibras de PMMA aumentó las propiedades mecánicas de la matriz de resina.

Self-efficacy and OSCE performance among second year medical students.

Competent performance requires not only requisite knowledge and skills but also beliefs of personal efficacy to use both effectively. This study examined the confidence of second-year medical students regarding their OSCE performance. Students completed an OSCE at the end of their second year of medical school; their performance was rated using checklists containing key items. Ten minutes prior to the OSCE, students completed a brief survey, which included 31 items sampling confidence in performing various clinical skills required in the OSCE. In addition, students assessed their preparedness and their anxiety, and reported the number of hours they studied in preparation for the OSCE. A total of 82 identifiable surveys (73 %) were used in this analysis. Students with high self-efficacy were more likely to score above the mean OSCE performance compared to low self-rated students (71% versus 51%), however self-efficacy was not significantly correlated to OSCE performance. A causal path model was constructed to predict OSCE performance. Performance in the clinical skills and biomedical science curricula both were related to perceived anxiety, which was related to self-efficacy. Preparedness was predicated on self-efficacy and itself predicted performance. Knowledge also had a strong direct link to performance. Performance is more than having the requisite abilities. Performance was found to be the product of complex relationships between skills and knowledge, mediated by perceptions of anxiety, self-confidence and preparedness. The model illustrates the importance of realistic self-appraisal for competent performance.

A survey of student assessment in U.S. medical schools: the balance of breadth versus fidelity.

BACKGROUND: Faced with the challenge to develop models of assessment relevant to work of physicians, medical schools have broadened their assessment of medical student competency. PURPOSE: U.S. medical schools were surveyed to determine the extent to which student assessments have broadened beyond multiple-choice question (MCQ) examinations and preceptor ratings. METHODS: A survey mailed to 126 accredited U.S. medical schools asked respondents to indicate the frequency with which a variety of assessment methods were used in each year of the curriculum. RESULTS: Examinations dominated preclinical assessments. Year 3 relied heavily on faculty ratings, live observations, and MCQs. Preceptor ratings were used most in year 4. CONCLUSIONS: A variety of competency assessments currently are used; MCQs remain a core assessment method. Year 3 had the greatest breadth of assessment strategies. The findings suggest that educators continue to be challenged to balance the breadth of competencies sampled with the fidelity of the assessment experience.

Pilot test of family medicine faculty development fellowship accreditation guidelines.

BACKGROUND: We conducted a pilot test of accreditation guidelines for family medicine faculty development fellowship programs from September 1997 to March 1999. The accreditation guidelines included 8 application categories with 27 requirements and 5 self-study criteria. The process included completion of the accreditation application and self-study and a site visit. We selected 6 sites for participation in the pilot test, and 5 sites completed all steps. The results indicated that, while fellowship faculty felt that the requirements and criteria were valid for determining quality of faculty development fellowship programs, the process was time-consuming and could be shortened. Redundancy between information supplied on the application and on the self-study was also noted. Six recommendations were included in the final report, including streamlining the accreditation process, developing guidelines for probationary status, and considering alternatives to accreditation, such as peer review.

Does studying for an objective structured clinical examination make a difference?

PURPOSE: This study examines the extent to which second-year medical students studied for an objective structured clinical examination (OSCE), how they studied, and the impact of self-reported studying on OSCE performance. METHOD: One class of 113 medical students completed an end-of-second-year OSCE, held on two consecutive evenings. The OSCE was comprised of eight stations, each of which was of 20 minutes' duration. The OSCE was formative: students received performance feedback but were not graded. Prior to the OSCE, students completed a brief survey regarding their preparation for the OSCE and their perceptions of confidence, anxiety and preparedness. Only 78 students returned surveys with names, comprising the data for these analyses. RESULTS: Mean studying time was 3.3 h, ranging from 0 to 19 h. Studying time was positively associated with age and negatively associated with basic science examination scores. The most study time was dedicated to reviewing the physical examination textbook, class notes and supplemental course readings. The breadth of study strategies increased as more time was spent in OSCE preparation. OSCE performance was related to study time and to achievement on pre-clinical basic science examinations. DISCUSSION: The students whose performance was above average seemed to be the talented students whose records indicated a history of academic success. The amount of time they reported for OSCE preparation was comparable to that reported by students with below average performance. It appears that prior academic performance rather than preparatory studying time is a better predictor of OSCE outcomes.

Recruitment behavior and program directors: how ethical are their perspectives about the match process?

OBJECTIVE: This study examined family practice residency directors' perspectives on the 1999 National Resident Matching Program (NRMP) process and identified directors' expectations for students' recruitment behavior. METHODS: Subjects were the family practice residency program directors. A 22-item written questionnaire was mailed to each director. The questions related to the directors' perceptions of the following issues: applicants interviewing in more than one specialty, communication initiated by programs or applicants, commitments made to applicants and by applicants, ethical dilemmas faced by the program director, and the NRMP process itself. Descriptive statistics were reported. RESULTS: Only a few of the residency program directors (9.1%) felt that it was ethically wrong for an applicant to interview in more than one specialty. However, most program directors (83%) indicated that the knowledge of an applicant interviewing in more than one specialty had a "significant" negative or "some" negative effect on the applicant's rank order. Ninety-five percent of program directors indicated that they engage in follow-up communication with applicants following the formal interview. Almost all program directors (98%) reported that at least some applicants contact them following the formal interview to inform them that the program was a "high" or No. 1 rank-order choice. The majority of program directors (94%) felt that the NRMP process placed their program in the position of having to be dishonest with applicants to match their top choices. CONCLUSIONS: The results of the study indicate that the actions of many program directors and applicants may not be consistent with the written policies of the NRMP.

Feeling the stress: perceptions of burnout among general surgery program directors.

PURPOSE: To document the types and levels of stress experienced by general surgery program directors as they fulfill their education and administrative responsibilities. METHODS: This study consisted of a 3-part survey that incorporated 2 established instruments to help determine the presence of burnout in program directors. A personal projects analysis was used to help identify the tasks most relevant to the role of program director as well as to evaluate their perceptions of these tasks. The Maslach Burnout Inventory (MBI) was used to measure the degree of burnout among program directors. Demographic data were gathered to develop a picture of the background of the program directors and how they spent their time. RESULTS: A total of 71.8% of program directors responded. Of all tasks, teaching received the highest ratings for importance, enjoyment, and control, as well as the lowest ratings for stress. Emotional exhaustion was the most notable aspect of burnout in program directors on the MBI. Program directors scoring high in burnout were younger, had been in their current position fewer years, and had fewer years overall as a program director. CONCLUSIONS: Burnout is more related to age and experience of program director than to features of the program itself.

The influence of recovery status and education on addiction counselors' approach to treatment.

The goal of this study is to examine the influence of education and recovery status on substance abuse treatment counselors' approach to patients. Three hundred forty-four drug abuse and alcoholism treatment counselors were questioned about treatment goals. A subgroup of 197 were also questioned about treatment practices. The influences of education and recovery status on the choice of treatment goals and treatment practices were examined through structural modeling procedures. Level of education influenced neither treatment goals nor techniques. Being in recovery, however, was associated with more varied treatment techniques and a broader range of treatment goals. The other variable related to treatment goals and practices was treatment modality. Working in residential programs was linked to a wider range of treatment goals and treatment practices. Implications of these findings for counselor training and the movement to professionalize substance abuse treatment are discussed.

Substance abuse treatment staff: recovery status and approaches to treatment.

Recovery status is an important characteristic of staff members working within substance abuse treatment. Recovering and nonrecovering staff members were contrasted previously, however there is a third group: Individuals who are not recovering themselves but are part of families with recovering or addicted members. The purpose of the present study is to compare background, roles within program and approaches to treatment of these three groups. Six hundred and thirty-four staff members of fifty-one treatment programs completed questionnaires. Five hundred and seventy-five completed an item indicating their recovery status. Forty-four percent identified themselves as nonrecovering, 30 percent as recovering, and 26 percent as nonrecovering but part of families with an addicted or recovering member. Nonrecovering staff with addicted or recovering family members differed from the other two groups on gender, more of them were female, but were similar to nonrecovering staff in their approach to treatment but fell between recovering and nonrecovering staff on measures of roles within programs and background. Recovering counselors reported to pursue a wider range of treatment goals and to use more varied treatment techniques than nonrecovering counselors. The implication of these findings for training and licensure of paraprofessionals in the field of substance abuse treatment is discussed.

The value of noncognitive factors in predicting students' first-year academic probation.

PURPOSE: To test the value of Sedlacek's Noncognitive Questionnaire (NQ) in predicting the risk of academic probation for first-year students at the College of Human Medicine at Michigan State University. METHOD: Ninety-six of 106 students completed the NQ during their first week of medical school. The NQ assesses the students in eight noncognitive domains such as academic positive self-concept and realistic self-appraisal. Using a previously derived grade-point average (GPA) and Medical College Admission Test (MCAT)-based risk-prediction equation, students were classified as high- or low-risk for first-year academic probation. At the end of their first year, students actually on probation were identified. RESULTS: High-risk students scored significantly higher than did low-risk students in both academic positive self-concept and realistic self-appraisal. The NQ factors alone predicted risk at a 70% accuracy rate, slightly lower than when the previously derived risk equation was used (74%). CONCLUSION: Sedlacek's noncognitive factors did not improve upon a prediction of academic probation based on GPA and MCAT scores. Sedlacek's NQ may lack the sensitivity required for use with medical students. Further research may identify more appropriate noncognitive factors.

Postal surveys versus electronic mail surveys. The tortoise and the hare revisited.

The advent of computer-based technology has led to a consideration of change in research methods that exploit the advantages of computer-mediated communications. In survey research, electronic mail (e-mail) has anecdotally shown particular promise as a data collection tool. This article compares traditional postal and nontraditional e-mail surveys within the context of a larger listserv evaluation project in terms of overall return rate, distribution of survey returns over time, response to initial and follow-up mailings, representativeness of respondent groups, thoroughness of survey completion, and the likelihood of respondents to include additional written comments. In summary, whereas postal surveys were shown to be superior to e-mail surveys with regard to response rate, all things being equal, the decision of which to use may be situation-specific, dependent on issues such as survey cost, desire for convenience and timeliness in data collection, and need for higher response rates, among others.

Graduating medical students' competencies and educational experiences in palliative care.

Palliative care involves an interdisciplinary approach to patient care and specific clinical skills. Little prior research on palliative care education has involved medical students, and the few reported studies focus mainly on student attitudes. This study describes a needs assessment of senior medical students based on a newly developed competency-based palliative care curriculum. Prior to graduation, 102 senior students were mailed an anonymous survey with four parts: a self-assessment of attitudes, knowledge, and skills; adequacy of instruction; exposure to specific clinical experiences; and demographic information. The response rate was 47%. While attitudinal goals were strongly endorsed by students, they were less confident with regards to knowledge and skills. Ratings varied across the five content areas of the curriculum. The results suggest a need for educational efforts more focused on specific clinical competencies as well as systematic evaluation of student competencies.

The emperor's new clothes: the OSCE reassessed.

In response to increasing concerns about the prevalence of knowledge- based assessments of medical student competency, leaders in medical education have emphasized the importance of methods that quantify student performance. As a result, the use of objective structured clinical examinations (OSCEs) is viewed by many as the newest and most promising technique for assessing students' abilities. In considering the implementation of a fourth-year OSCE, faculty at the College of Human Medicine at Michigan State University became uncomfortable with some of the technical limitations of the method (limited generalizability; weak linkages to the curriculum; little opportunity provided for improvement in examinees' skills; and others), as well as the possible ramifications of such an innovation within their school's specific curricular and organizational contexts. This essay is offered as a reflection of the challenges and possible alternatives that have emerged as the faculty have considered how best to design and implement performance-based assessment within their institution. Rather than using the OSCE as a milestone marker of student performance, they consider the possibility of smaller assessment events, closely tied to the curriculum and consistent with the guiding principles of the medical school.

Sources of coming out self-efficacy for lesbians.

The empirical literature on disclosing a lesbian sexual orientation has explored the circumstantial and demographic variables related to this act. This exploratory study utilized self-efficacy theory (Bandura, 1986) to investigate the extent to which each of the four sources of efficacy information (e.g., performance accomplishments, vicarious experience, verbal persuasion, or emotional arousal) contributed to the coming out self-efficacy of lesbians, that is, the sense of confidence possessed by a lesbian to disclose her sexual orientation to others. Anonymous survey packets were completed by 134 lesbians. Results of regression analyses indicated that emotional arousal was the most potent predictor of coming out self-efficacy. Verbal persuasion and vicarious experience also were significant. The most theoretically salient source of self-efficacy information, performance accomplishments (Bandura, 1986), was not a significant predictor of coming out self-efficacy. Further, significant correlations were found between coming out self-efficacy and outness and life-style satisfaction, which were also significantly correlated to measures of psychological adjustment.

The effect of testing time on students' performance for the subject examination for internal medicine.

The authors tested the hypothesis that increasing the allotted testing time from two to four hours for the National Board of Medical Examiners medicine subject examination would increase the score on this examination when given as part of the clerkship evaluation. One-hundred six students who completed their medicine clerkships between September 1991 and August 1992 (group 1) were compared with 96 students who completed their clerkships between September 1992 and August 1993 (group 2). The mean medicine subject examination score for group 1 was 462 +/- 86, vs 518 +/- 108 for group 2 (p = 0.0003). Regression analysis using the medicine subject examination score as the dependent variable and all baseline characteristics, group assignment, and time of year the test was taken as independent variables demonstrated significant interactions only for United States Medical Licensing Examination (USMLE) Step 1 score (R2 = 0.48, beta weight = 0.68, p = 0.0000) and group assignment (R2 = 0.05, beta weight = 0.18, p = 0.002). The authors conclude that increased testing time for the medicine subject examination from two to four hours is associated with a significant increase in scores; however, scores on the preclinical USMLE Step 1 showed a stronger association.

The relationship between career satisfaction and fellowship training in academic surgeons.

BACKGROUND: Academic surgeons make various important decisions about their careers; however, little is known about the relationships between fellowship training, career development issues, and academic responsibilities. METHODS: Surgeon members of the Association for Surgical Education were surveyed about career development issues. Three hundred ninety-two (75.2%) surgeons responded. RESULTS: An exploratory factor analysis of the career development issues revealed four career development factors. Statistically significant differences were found between types of fellowship training and the career development factors. Nonfellowship-trained and clinical-fellowship-trained surgeons spend their time similarly to physicians in other specialties. Research-fellowship-trained surgeons spent significantly more time doing research, had fewer concerns about professional confidence, and expressed greater satisfaction with their careers. CONCLUSION: There is a relationship between career development issues, fellowship training, and type of fellowship training. Attention to these issues may be important in recruiting and retaining academic surgeons.

The longitudinal stability of the Addiction Severity Index.

The Addiction Severity Index (ASI) is a structured interview widely used by substance abuse clinicians and researchers for client screening, determining treatment needs, and assessing treatment outcomes. Previous researchers have evaluated inter-rater agreement, test-retest reliability, and concurrent validity. The present report describes the stability of ASI scores in longitudinal work. In the context of an ongoing treatment outcome evaluation study involving seven assessors, inter-rater agreement, inter-rater reliability, as well as intra- and inter-rater accuracy were assessed repeatedly during a 2-year period. The results show the scores derived from the ASI to be stable across assessors and over time. The relationship between stable scores and resources required for training are discussed.

Key modifiable factors in weight maintenance: fat intake, exercise, and weight cycling.

OBJECTIVE: This 6- to 42-month follow-up study of a 6-month worksite weight control intervention examined predictors of weight maintenance, with a focus on those that could be modified. SUBJECTS: Twenty-nine participants, 14 men and 15 women, from a behavior modification program completed follow-up measurements. MAIN OUTCOME MEASURES: Height, weight, waist-to-hip ratio, food and beverage intake from a 3-day food record, weight history, social support and physical activity were the main outcome measures. RESULTS: One third of the participants maintained their weight losses within 2 kg at follow-up, although all had higher relative weights at follow-up than immediately after the program. High daily fat consumption (r = .40) and reduced time in physical activity (r = .34) correlated with increased relative weight at follow-up (P < .05). APPLICATION: Because previous weight cycling was so strongly related to weight loss maintenance (r = .55), potential weight program participants should learn and practice the weight maintenance behaviors of reduced dietary fat and regular exercise, independently of and before weight reduction attempts.

Program factors influencing client satisfaction in alcohol treatment.

There is little documentation about how the union of self-help and professional treatment services influences client treatment satisfaction. This study examines the relationship of treatment characteristics indicative of program size, staffing patterns, Alcoholics Anonymous (AA) influence, and staff recovery status to client satisfaction. Thirty-six public substance abuse treatment programs participated in this study. At outpatient programs, satisfaction was related to program size, and the number of paraprofessional and medical staff; satisfaction was unrelated to AA influence on treatment. For residential clients, AA influence on treatment and AA beliefs held by staff were consistently related to satisfaction; factors related to program size and staffing patterns were independent of satisfaction. The results question the appropriateness of self-help interventions in all settings, and emphasize contextual differences in outpatient and residential programs.