Working in the dead of night: exploring the transition to after-hours duty.

CONTEXT: Transitions, although often difficult, represent integral components of medical training. New postgraduate trainees (first-year residents) find themselves in an especially challenging transition as they are expected to fulfil both learning and service expectations concurrently. Workplace learning theory has been suggested as a lens through which to understand this unique educational, yet service-oriented, role. This tension may be further amplified overnight when residents are on-call with little to no support. OBJECTIVES: The aims of this study were to explore the transition from medical student to resident with respect to the on-call experience, and to provide theory-based suggestions to enhance learning during this unique transition. METHODS: We conducted an interpretivist qualitative study by interviewing eight medical students and 10 first-year residents from six different specialty training programmes across four academic sites. Each semi-structured interview was transcribed verbatim and anonymised. Resident interview transcripts were initially coded for major themes, after which medical student interview transcripts were coded for consistencies and discrepancies. RESULTS: Four interrelated themes were identified in students' and residents' descriptions of on-call experiences: (i) shift in responsibility; (ii) supervisory support; (iii) contextual conditions, and (iv) clarity of expectations. Generally, students were not able to anticipate the challenges they would face as residents on-call, and residents perceived the transition as sudden with little emphasis placed on learning. CONCLUSIONS: First-year residents face multiple challenges during on-call, which may prevent optimal learning in this setting. These challenges are amplified by the large gap between the respective roles of medical students and residents. We identified promoters of and barriers to effective learning in this environment and, by using workplace learning theory, provide recommendations for how we might be able to enhance medical students' preparation for and first-year residents' learning during experiences of being on-call.

Diagnosing technical competence in six bedside procedures: comparing checklists and a global rating scale in the assessment of resident performance.

PURPOSE: To compare procedure-specific checklists and a global rating scale in assessing technical competence. METHOD: Two trained raters used procedure-specific checklists and a global rating scale to independently evaluate 218 video-recorded performances of six bedside procedures of varying complexity for technical competence. The procedures were completed by 47 residents participating in a formative simulation-based objective structured clinical examination at the University of Calgary in 2011. Pass/fail (competent/not competent) decisions were based on an overall global assessment item on the global rating scale. Raters provided written comments on performances they deemed not competent. Checklist minimum passing levels were set using traditional standard-setting methods. RESULTS: For each procedure, the global rating scale demonstrated higher internal reliability and lower interrater reliability than the checklist. However, interrater reliability was almost perfect for decisions on competence using the overall global assessment (Kappa range: 0.84-1.00). Clinically significant procedural errors were most often cited as reasons for ratings of not competent. Using checklist scores to diagnose competence demonstrated acceptable discrimination: The area under the curve ranged from 0.84 (95% CI 0.72-0.97) to 0.93 (95% CI 0.82-1.00). Checklist minimum passing levels demonstrated high sensitivity but low specificity for diagnosing competence. CONCLUSIONS: Assessment using a global rating scale may be superior to assessment using a checklist for evaluation of technical competence. Traditional standard-setting methods may establish checklist cut scores with too-low specificity: High checklist scores did not rule out incompetence. The role of clinically significant errors in determining procedural competence should be further evaluated.

Expression profiles of mRNA transcript variants encoding the human inhibitor of growth tumor suppressor gene family in normal and neoplastic tissues.

The INhibitor of Growth (ING) tumor suppressor gene family is important in regulating cell fate and reads the epigenetic code by interacting specifically with methylated histone H3. Several transcript variants are expressed from the five ING genes but nomenclature for these variants are not consistent in the literature, and very little is known regarding transcript variant expression in normal human tissues and during development. Here we propose a standardized nomenclature for human ING gene family transcript variants and present an expression analysis using real-time quantitative PCR. We establish the steady-state levels of eleven human ING mRNA transcript variants across several fetal, adult, and tumor tissues as well as in cancer-derived cell lines. Consistent with their roles as type II tumor suppressors, we find up to 10,000-fold reduction in many transcript variants in a subset of neoplastic cells. We also find considerable variation in expression levels in different tissues, with up to 1 million-fold higher expression of some ING transcripts in adult, compared to fetal counterparts, particularly in the brain cerebral cortex. These results show differential expression of specific subsets of ING1-5 transcript variants in tissues that may influence the degree to which these variants contribute to epigenetic regulation in cancer and development.