Madness and method in stress echo reading.
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AIM: To assess whether 'eye education' through short-term, high-intensity joint reading sessions may improve diagnostic accuracy and inter-observer agreement among beginners. METHODS AND RESULTS: Seventeen cardiologists with absent to minimal (<100 studies performed) previous stress echo experience independently and blindly read 18 stress echo studies, nine at the beginning ('pre-training' set) and nine at the end ('post-training' set) of a 2 day stress echo school which included a joint reading session of 50 tapes. The two sets were balanced as far as type of stress and image quality. The 17 observers had an average accuracy score of 51+/-16.4 before and 64.3+/-8.7% after the training (P<0.005). Concordant (i.e. >14 readers giving the same response) interpretation occurred in three out of nine studies before and in eight out of nine studies after the training (33% vs 88%, P<0.01). Kappa values went from 0.14 (poor) before to 0.39 (fair, close to moderate) after the training. CONCLUSION: Short-term, high-intensity dedicated training in stress echo, with joint reading sessions and consensus development of reading criteria significantly increased accuracy and markedly reduced the inter-observer variability in the reading of stress echoes by beginners. If there is a Shakespearean madness in stress echo reading, 'yet there is a method in't' (Hamlet, II, II, 205-206). (+info)
Evaluation of laparoscopic skills: a 2-year follow-up during residency training.
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OBJECTIVE: To evaluate laparoscopic technical skill in surgical residents over a 2-year period. DESIGN: The laparoscopic technical skills of general surgical residents were evaluated using the MISTELS program. This provides an objective evaluation of laparoscopic skill, taking into account precision and speed. SETTING: Inanimate laparoscopic skills centre. PARTICIPANTS: Ten general surgical residents (5 PGY1, 3 PGY2 and 2 PGY3 residents) who were required to complete 3 structured laparoscopic tasks. OUTCOME MEASURES: A composite score incorporating precision and timing was assigned to each task. The paired t-test was used to compare performance of each resident at the 2 levels of their residency training for each task. Linear regression analysis was used to correlated level of training and total score (sum of all tasks). RESULTS: Linear regression analysis demonstrated a highly significant correlation between level of training and total score (r = 0.82, p < 0.01). There was a significant increase in scores in the cutting and suturing task over the 2-year period (p < 0.01). Transferring skills did not improve significantly (p = 0.11). CONCLUSIONS: Performance in the simulator improved over residency training and was correlated highly with postgraduate year. This simulator model is a valuable teaching tool for training and evaluation of basic laparoscopic tasks in laparoscopic surgery. (+info)
Teaching family practice residents breast cyst aspiration.
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OBJECTIVE: To conduct the first study of teaching family practice residents the technique of breast cyst aspiration (BCA) using the Toronto Breast Cyst Aspiration Model (TBCAM) in a workshop. To determine whether this training increases their likelihood of performing the procedure in the future. To discover how residents evaluate the workshop as a teaching method. DESIGN: Prospective parallel-group trial from August to November 1997. Baseline questionnaires were given to both experimental and control groups in August. The experimental group was given a 1.5-hour workshop and a postworkshop questionnaire. Both groups were then given 3-month follow-up questionnaires. SETTING: Family practice residency program at the University of Toronto. PARTICIPANTS: The experimental group consisted of 15 family practice residents from one university-affiliated hospital site. The control group consisted of 54 family practice residents selected from the remaining sites. MAIN OUTCOME MEASURES: Confidence score, likelihood of performing BCA, and effectiveness of the workshop rated on a Likert scale ranging from 1-low to 5-high; and knowledge of BCA rated from 0 to 7. RESULTS: Three months after the workshop, 62% of study subjects and 31% of controls were above the median confidence score of 3.2 (chi 2 3.4, P > .05); 76% of subjects but only 11% of controls were above the median knowledge score of 4 (chi 2 16.67, P < .001); and 75% of subjects and 34% of controls were above the median likelihood to perform score of 3 (chi 2 5.37, P < .05). Most (95%) workshop effectiveness scores were 4s or 5s. CONCLUSIONS: Workshop training resulted in higher confidence, greater knowledge, and more likelihood of performing BCA. The workshop using the TBCAM was evaluated as a highly effective way to teach BCA. (+info)
Are doctors still failing to assess and treat asthma attacks? An audit of the management of acute attacks in a health district.
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This audit aimed to observe the management of acute asthma by primary and secondary care within a Health District. Asthma attacks occurring during the first 6 weeks of 1996 to patients between the ages of 3 and 74 years in Canterbury and Thanet District were notified by general practitioners, out-of-hours co-operatives and hospitals. Data were obtained retrospectively from the patient records. A total of 378 episodes was registered: 342 (90%) to primary care. Of these 234 (76% of patients aged 6 years or over) had a peak flow recorded; 114 (30%) were given emergency bronchodilation: oxygen was not used in primary care; 204 (54%) were given systemic steroids; and 43 (11%) were referred for hospital care of whom 36 were admitted. Of the attacks, 212 (69% of the patients aged 6 years or over) could be classified by percentage predicted peak flow and management compared to the Guidelines published by the British Thoracic Society. Twenty-eight patients presented with 'life-threatening' asthma: 20 (71%) were given emergency bronchodilation; oxygen was used in only two; 24 (86%) were given systemic steroids; and six (21%) were referred for admission. In their confidential enquiry into the asthma deaths the British Thoracic Society identified a failure to appreciate the severity of the attack, resulting in inadequate emergency treatment and delay in referring to hospital. These data suggest that, 15 years later, these problems may still exist. (+info)
Clinical experience during the paediatric undergraduate course.
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Medical students at the Cambridge Clinical School are provided with a list of 42 core conditions they should encounter and 20 core skills they should perform during their attachment. By self-completion questionnaires we assessed their clinical experience and the amount of teaching they received, relating the results to marks gained in end-of-attachment assessments. 103 (93%) of 110 students in year one and 123 (96%) of 128 in year two completed the questionnaires. Of the 42 core conditions, 13 were seen by under 70% of the students in year one. In year two, exposure rate increased for 26 core conditions by a median of 7% (range 2-40) and decreased in 13 core conditions by a median value 4% (range 5-13) (P = 0.0005, chi 2). Only mandatory core skills were performed by over 90% of students. 5% of students did not perform any newborn examinations and under 60% observed neonatal resuscitation or a high-risk delivery. Students' core condition score was associated with their core skill score (r = 0.5), hospital grade (r = 0.3) and exposure to acute paediatrics (r = 0.3) (P < 0.005). There was no significant association between clinical experience and the objective examination score or the amount of teaching received. There was an inverse association between the number of students at a hospital and the number of core conditions with an exposure rate above 70% at that hospital (r = 0.7, P < 0.05). This study suggests that clinical experience may be better judged by the clinical supervisor than by assessment of theoretical knowledge. (+info)
Confidential prescriber feedback and education to improve antibiotic use in primary care: a controlled trial.
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BACKGROUND: Antibiotics are a medication class for which inappropriate prescribing is frequently described. We sought to assess the effectiveness of a mailed intervention combining confidential prescribing feedback with targeted educational bulletins in increasing the use of less expensive, first-line antibiotics by practising physicians. METHODS: The participants were 251 randomly selected primary care physicians from southern Ontario who consented to participate (135 in the feedback group and 116 in the control group). Prescribing data were obtained from the claims database of the Ontario Drug Benefit program, which covers all Ontarians over age 65 years for drugs selected from a minimally restrictive formulary. Confidentially prepared profiles of antibiotic prescriptions coupled with guidelines-based educational bulletins were mailed to the intervention group every 2 months for 6 months. The control group received no intervention until after completion of the study. The main outcome measures were change from baseline in physician's median antibiotic cost and proportion of episodes of care in which a prespecified first-line antibiotic was used first. RESULTS: The median prescription cost of about $11 remained constant in the feedback group but rose in the control group (change of $0.05 v. $3.37, p < 0.002). First-line drug use increased in the feedback group but decreased in the control group (change of 2.6% v. -1.7%, p < 0.01). In a mailed survey of 100 feedback recipients (response rate 76%), 82% indicated that they would participate readily in another, similar program. INTERPRETATION: A simple program of confidential feedback and educational materials blunted cost increases, increased the use of first-line antibiotics and was highly acceptable to Ontario primary care physicians. (+info)
Multifaceted shared care intervention for late life depression in residential care: randomised controlled trial.
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OBJECTIVE: To evaluate the effectiveness of a population based, multifaceted shared care intervention for late life depression in residential care. DESIGN: Randomised controlled trial, with control and intervention groups studied one after the other and blind follow up after 9.5 months. SETTING: Population of residential facility in Sydney living in self care units and hostels. PARTICIPANTS: 220 depressed residents aged >/=65 without severe cognitive impairment. INTERVENTION: The shared care intervention included: (a) multidisciplinary consultation and collaboration, (b) training of general practitioners and carers in detection and management of depression, and (c) depression related health education and activity programmes for residents. The control group received routine care. MAIN OUTCOME MEASURE: Geriatric depression scale. RESULTS: Intention to treat analysis was used. There was significantly more movement to "less depressed" levels of depression at follow up in the intervention than control group (Mantel-Haenszel stratification test, P=0.0125). Multiple linear regression analysis found a significant intervention effect after controlling for possible confounders, with the intervention group showing an average improvement of 1.87 points on the geriatric depression scale compared with the control group (95% confidence interval 0.76 to 2.97, P=0.0011). CONCLUSIONS: The outcome of depression among elderly people in residential care can be improved by multidisciplinary collaboration, by enhancing the clinical skills of general practitioners and care staff, and by providing depression related health education and activity programmes for residents. (+info)
A pilot study of peer review in residency training.
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OBJECTIVE: To explore the utility of peer review (review by fellow interns or residents in the firm) as an additional method of evaluation in a university categorical internal medicine residency program. DESIGN/PARTICIPANTS: Senior residents and interns were asked to complete evaluations of interns at the end-of-month ward rotations. MAIN RESULTS: Response rates for senior residents evaluating 16 interns were 70%; for interns evaluating interns, 35%. Analysis of 177 instruments for 16 interns showed high internal consistency in the evaluations. Factor analysis supported a two-dimensional view of clinical competence. Correlations between faculty, senior resident, and intern assessments of interns were good, although varied by domain. CONCLUSIONS: An end-of-year attitude survey found that residents gave high ratings to the value of feedback from peers. (+info)