The script clinical reasoning test An internal medicine educational practice perspective

One of the main skills in internal medicine is clinical decision making. To make clinical decisions, physicians in training reorganize their knowledge in order to optimally perform their clinical functions (diagnosis, research methods and treatment), which are organized according to disease scripts. This ability develops with experience and is acquired during their academic training. The script concordance test has been described as an innovative evaluation tool, designed to evaluate clinical decision making (clinical reasoning) in addition to the degree of knowledge. The script theory, understood as the organization of knowledge, is the basis for decision making. Disease scripts play a key role in supporting and developing clinical reasoning skills, which should be acquired in order to produce differential diagnoses and interpret clinical data. (Acta Med Colomb 2022; 48. DOI:https://doi.org/10.36104/amc.2023.2569).

Abriendo la caja de Pandora: ¿qué contienen los instrumentos que miden el ambiente de aprendizaje en medicina? / Opening Pandoras Box: What is the Content of the Instruments Measuring the Learning Environment in Medicine?

RESUMEN Introducción/objetivo: La medición del ambiente de aprendizaje en medicina es fundamental para evaluar la calidad de la educación médica. Existen múltiples instrumentos diseñados para este propósito, pero su contenido, fundamento teórico y utilidad práctica son variables. El objetivo de este estudio es sintetizar la validez de contenido y alcance de estos instrumentos. Métodos: Se realizó una revisión sistemática de la literatura de estudios originales en idioma inglés y español publicados desde 1990 hasta 2018 en las bases de datos de Pubmed, ERIC, British Nursing Index, Google Scholar, Science Direct, Cochrane, CINALH y Latindex, que contienen instrumentos para medir el ambiente de aprendizaje en medicina. Se analizaron los dominios, fundamentos teóricos y métodos para determinar la validez de contenido. Resultados: Se incluyeron treinta y ocho estudios que evaluaron doce instrumentos (uno disponible en español). Dos instrumentos identificados fueron específicos para el ambiente quirúrgico y uno para el comunitario. Únicamente tres instrumentos estuvieron respaldados por una teoría educativa. Los dominios más frecuentemente evaluados fueron la atmosfera del aprendizaje, la percepción social y percepción académica. La validez de contenido se estableció principalmente mediante un panel de expertos o método Delphi en el 83,3 % de los instrumentos. Conclusiones: Existen diversos instrumentos para evaluar un constructo complejo como el ambiente de aprendizaje en medicina. En general, estos instrumentos cuentan con validez de contenido respaldada por múltiples fuentes y metodologías, y pueden ser utilizados por los educadores médicos para evaluar de forma integral el ambiente de aprendizaje.

ABSTRACT Introduction/aim: The measurement of the learning environment in medicine is fundamental to assess the quality of medical education. Multiple instruments are available for this purpose, but their content, theoretical foundations and practical implications variate. Our aim is to synthesize the content validity and scope of these instruments. Methods: We conducted a systematic review of original studies designed to measure the learning environment in medicine, published in English and Spanish languages, from 1990 to 2018. We search for studies in Pubmed, ERIC, British Nursing Index, Google Scholar, Science Direct, Cochrane, CINALH and Latindex. We analyzed the main domains, theoretical foundations and methods to determine the content validity of each instrument. Results: Thirty-eight studies evaluating twelve instruments (one available in Spanish) were included. Two instruments were specific for the surgical environment and one for the community. Only three instruments were supported by an educational theory. The domains most frequently evaluated were the atmosphere, social perception and academic perception of learning. The content validity was established through expert panels or Delphi method in 83,3 % of the instruments. Conclusions: There are several instruments to evaluate a complex construct such as the learning environment in medicine. In general, these instruments have content validity supported by multiple sources and methodologies and they can be used by medical educators to assess the learning environment comprehensively.

Profilaxis y educación en migraña y cefalea tensional: una percepción de la eficacia de las prácticas de los médicos de atención primaria / Prophylaxis and education for migraine and tension type headache: a perception of the effectiveness of the practices of primary health physicians

RESUMEN INTRODUCCIÓN: La migraña y la cefalea tipo tensional son los dolores de cabeza primarios más frecuentes en la consulta médica; la mejoría clínica de los pacientes se relaciona con la educación brindada y la prescripción de tratamientos profilácticos por parte de sus médicos tratantes. OBJETIVO: Determinar la frecuencia de prescripción del tratamiento profiláctico y de la realización de explicaciones educativas al paciente con cefalea primaria por parte de los médicos de atención primaria, además de los factores asociados a ellas. MATERIALES Y MÉTODOS: Estudio de corte transversal con 152 pacientes con criterios para migraña o cefalea tensional de la ICHD y con indicación para tratamiento profiláctico según las guías canadienses, que fueron atendidos por médicos de atención primaria. Se aplicó un cuestionario para establecer el tipo de prácticas realizadas por los profesionales y se realizó un análisis univariado y bivariado. RESULTADOS: Solo al 23 % de los pacientes le formularon tratamiento profiláctico, el 56 % nunca recibió explicación educativa sobre su enfermedad y el 70 °% nunca había sido remitido a consulta de neurología. El 44 °% respondió no saber sobre el origen de la cefalea y se encontró una asociación significativa entre el nivel educativo del paciente y el hecho que le ofrecieran explicación educativa. CONCLUSION: La frecuencia en la formulación de profilaxis farmacológica y realización de explicaciones educativas al paciente por parte del médico de atención primaria fue baja. Esto puede relacionarse con un desconocimiento de los protocolos de manejo en cefalea primaria y fallas en las habilidades clínicas recibidas en el pregrado.

SUMMARY INTRODUCTION: Migraine and tension type headache are the most frequent primary headaches in the medical practice; the clinical improvement of the patients is related to the education carry out by his physician and the prescription of prophylactic treatments. Migraine and tension-type headache are the most frequent primary headaches in the medical office; the clinical improvement of the patients is related to the education provided and the prescription of prophylactic treatments by their treating doctors. OBJECTIVE: To determine the frequency of prescription of prophylactic treatment and of educational explanations to the patient with primary headache by primary care physicians, and the possible factors associated with them. MATERIALS AND METHODS: Cross-sectional study with 152 patients that have Migraine or Tensional Headache according to the ICHD criteria and that had an indication for prophylactic treatment according to the Canadian guidelines for the prophylaxis management of patients with migraine, which were attended by primary care physicians. Application of a questionnaire to establish the type of practices carried out by professionals; an univariate and bivariate analysis was performed. RESULTS: 56 °% of the patients never received an educational explanation about their disease, 70 °% had never been referred to a neurology consultation previously, and 23 % had been prescribed prophylactic treatment. 44 °% answered not knowing about the origin of the headache and found a significant association between the educational level of the patient and the fact that they offered educational explanation. CONCLUSION: The frequency of formulation of pharmacological prophylaxis and the performance of educational explanations to the patient by the Primary Care Physician was very low; This may be related to a lack of knowledge of management protocols in primary headache and to flaws in the clinical skills previously obtained in undergraduate training.

[Correlation between socioeconomic factors and in-hospital mortality from ischemic stroke in a hospital cohort in Colombia, 2003-2006]. / Asociación entre factores socioeconómicos y mortalidad intrahospitalaria por accidente cerebrovascular isquémico en una cohorte hospitalaria de Colombia, 2003-2006.

OBJECTIVE: To determine if there is a correlation between socioeconomic conditions and in-hospital mortality (IHM) from ischemic stroke in a sample of the Colombian population and identify the chain of events that determine that association. METHODS: Prospective study of a hospital cohort of patients with ischemic stroke in four Colombian clinical referral institutions-located in Floridablanca, Bucaramanga, Bogotá, and Medellín-between February 2003 and December 2006. Hierarchical analysis was used to group the socioeconomic variables into three levels, and their relationship to IHM due to ischemic stroke was assessed in a Cox proportional hazards model. RESULTS: The IHM rate was 9.4% in the 253 patients included in the study. In the analysis by levels, mortality was inversely associated with educational level (advanced to primary), monthly income (≥ minimum wage), and participation in the contributory health system. When the three levels were combined in the hierarchical analysis, affiliation with the contributory system was the only association that maintained its statistical significance (RR 0.35; CI 95%: 0.13-0.96; P = 0.04). CONCLUSIONS: The results indicate that, in Colombia, being affiliated with the contributory health system is an independent protective factor against IHM after an ischemic stroke. The education-income-access to health services sequence is a possible explanation for the relationship between socioeconomic conditions and the clinical outcome of these events. Strategies should be designed to mitigate the differences in the quality and distribution of health services in the Colombian population.

Asociación entre factores socioeconómicos y mortalidad intrahospitalaria por accidente cerebrovascular isquémico en una cohorte hospitalaria de Colombia, 2003-2006 / Correlation between socioeconomic factors and in-hospital mortality from ischemic stroke in a hospital cohort in Colombia, 2003-2006

OBJETIVO: Determinar si existe asociación entre las condiciones socioeconómicas y la mortalidad intrahospitalaria (MIH) por accidente cerebrovascular (ACV) isquémico en una muestra de población colombiana e identificar la cadena de eventos que determinan esa asociación. MÉTODOS: Estudio prospectivo de una cohorte hospitalaria de pacientes con ACV isquémico registrados en cuatro instituciones clínicas de referencia colombianas -ubicadas en Floridablanca, Bucaramanga, Bogotá y Medellín- entre febrero de 2003 y diciembre de 2006. Mediante análisis jerárquico se evaluaron las variables socioeconómicas agrupadas en tres niveles para determinar su relación con la MIH por ACV isquémico en un modelo de riesgos proporcionales de Cox. RESULTADOS: En los 253 pacientes incluidos, la MIH fue de 9,4 %. En el análisis por niveles, la mortalidad estuvo inversamente asociada con el nivel educacional (estudios superiores a primaria), los ingresos mensuales (≥ salario mínimo) y la vinculación al régimen contributivo. En el análisis jerárquico, al combinar los 3 niveles, solo la asociación inversa con la afiliación al régimen contributivo mantuvo su significación estadística (RR 0,35; IC95%: 0,13-0,96; P = 0,04). CONCLUSIONES: Los resultados indican que en Colombia, el estar afilado al régimen contributivo de salud es un factor protector independiente contra la MIH tras un ACV isquémico. La secuencia educación-ingresos-acceso a servicios de salud constituye una vía de explicación de la relación entre las condiciones socioeconómicas y el desenlace clínico de estos eventos. Se deben diseñar estrategias para mitigar las diferencias en la calidad y la distribución de los servicios de salud en la población colombiana.

OBJECTIVE: To determine if there is a correlation between socioeconomic conditions and in-hospital mortality (IHM) from ischemic stroke in a sample of the Colombian population and identify the chain of events that determine that association. METHODS: Prospective study of a hospital cohort of patients with ischemic stroke in four Colombian clinical referral institutions-located in Floridablanca, Bucaramanga, Bogotá, and Medellín-between February 2003 and December 2006. Hierarchical analysis was used to group the socioeconomic variables into three levels, and their relationship to IHM due to ischemic stroke was assessed in a Cox proportional hazards model. RESULTS: The IHM rate was 9.4% in the 253 patients included in the study. In the analysis by levels, mortality was inversely associated with educational level (advanced to primary), monthly income (≥ minimum wage), and participation in the contributory health system. When the three levels were combined in the hierarchical analysis, affiliation with the contributory system was the only association that maintained its statistical significance (RR 0.35; CI 95%: 0.13-0.96; P = 0.04). CONCLUSIONS: The results indicate that, in Colombia, being affiliated with the contributory health system is an independent protective factor against IHM after an ischemic stroke. The education-income-access to health services sequence is a possible explanation for the relationship between socioeconomic conditions and the clinical outcome of these events. Strategies should be designed to mitigate the differences in the quality and distribution of health services in the Colombian population.