Sequential Objective Structured Clinical Examination based on item response theory in Iran / 보건의료교육평가

PURPOSE: In a sequential objective structured clinical examination (OSCE), all students initially take a short screening OSCE. Examinees who pass are excused from further testing, but an additional OSCE is administered to the remaining examinees. Previous investigations of sequential OSCE were based on classical test theory. We aimed to design and evaluate screening OSCEs based on item response theory (IRT). METHODS: We carried out a retrospective observational study. At each station of a 10-station OSCE, the students' performance was graded on a Likert-type scale. Since the data were polytomous, the difficulty parameters, discrimination parameters, and students' ability were calculated using a graded response model. To design several screening OSCEs, we identified the 5 most difficult stations and the 5 most discriminative ones. For each test, 5, 4, or 3 stations were selected. Normal and stringent cut-scores were defined for each test. We compared the results of each of the 12 screening OSCEs to the main OSCE and calculated the positive and negative predictive values (PPV and NPV), as well as the exam cost. RESULTS: A total of 253 students (95.1%) passed the main OSCE, while 72.6% to 94.4% of examinees passed the screening tests. The PPV values ranged from 0.98 to 1.00, and the NPV values ranged from 0.18 to 0.59. Two tests effectively predicted the results of the main exam, resulting in financial savings of 34% to 40%. CONCLUSION: If stations with the highest IRT-based discrimination values and stringent cut-scores are utilized in the screening test, sequential OSCE can be an efficient and convenient way to conduct an OSCE.

Misconceptions and integration

Introduction: Pervasive beliefs regarding curricular reform and integration have flourished among medical students, faculty members and medical school administrators. These concepts have extensively impacted the reform process, sometimes by resisting the reforms and sometimes by diverting the curriculum from its planned objectives. In the current paper, we have tried to address the challenges of integration in MD program by looking at the existing literature and the experience of the international universities

Methods: We collected the questions frequently asked during the curricular reform process. We, then, evaluated them, and selected 5 main ideas. In order to find their answers, we searched the literature using these keywords: integration, reform, and undergraduate medical curriculum

Results: The findings are discussed in five sections: 1] Reform is not equivalent to integration, 2] Integration can be implemented in both high school and graduate programs, 3] Organ-system based integration is not the only method available for integration, 4] Integration of two phases [basic sciences and physiopathology] can be considered but it is not mandatory, 5] Integration does not fade basic sciences in favor of clinical courses

Conclusion: It seems that medical education literature and prior experience of the leading universities do not support most of the usual concepts about integration. Therefore, it is important to consider informed decision making based on best evidence rather than personal opinions during the curricular reform process

Comparing the effect of pentoxifylline administration on mast cells maturing process in a diabetic and normoglycemic rat wound healing

Wound healing is a complicated process that is influenced by many factors. Studies at molecular level on human and animal models have revealed several molecular changes related to the effect of diabetes on wound healing process. Increasing number of researches implicates the influence of mast cells on skin wounds healing. The present experimental study was conducted to compare systemic pentoxifylline administration on maturing process of mast cells during skin wound healing in diabetic and normoglycemic rats. In this experimental study, 48 wistar rats were divided into 2 groups of normoglycemic and diabetic and each group was divided into experimental and control. Experimental group received intraperitoneal [25 mg/kg twice a day] and control group received distilled water. The number of mast cells and their maturing process was evaluated by microscopically counting of the types of mast cells [types 1, 2, 3] by stereological methods on day 3 and 7 after surgery. In all experimental groups receiving pentoxifylline there were significant difference in the number of total mast cells, comparing normoglycemic groups [p<0.05] and also we found that in wound healing process pentoxifylline caused increasing the number of type 2 mast cells in all experimental groups [p<0.05]. In all pentoxifylline treated groups delay in converting type 2 into type 3 mast cell was seen. Pentoxifylline causes decreasing mast cell degranulation during wound healing process

Effect of door-to-antibiotic time on mortality of patients with sepsis in emergency department: a prospective cohort study

Sepsis constitutes an important cause of hospital admission with a high mortality rate. Appropriate antibiotic therapy is the cornerstone of therapy in patients with sepsis. Although numerous studies have recommended early antibiotic initiation in severe sepsis or septic shock stages of sepsis syndrome, its role in treatment of patients with sepsis who have not entered these stages remains to be investigated. The purpose of this study is to investigate the effect of door-to-antibiotic time in sepsis patients with various degrees of severity. This is a longitudinal prospective cohort study on adult patients admitted with sepsis to the emergency department. Sepsis was defined as presence of at least two criteria of systemic inflammatory response syndrome and procalcitonin levels >/= 2 micro g/l. Severity of sepsis was determined using the APACHE II [Acute Physiology and Chronic Health Evaluation II] scoring system. Time to antibiotic administration was recorded and its relationship with mortality was assessed. A total of 145 patients were eligible for enrollment. The mean age was 60.4 years and the mean APACHE score was 13.7. The overall in-hospital mortality was 21.4%, and the mean length of stay in hospital was 211.9 hours. The mean door-to-antibiotic time for our patients was 104.4 minutes. Antibiotic administration time and mortality in patients with APACHE scores of 21 or higher [P=0.05] were significantly related; whereas such a relationship was not observed for patients with APACHE scores of 11- 20 [P=0.46]. We observed early antibiotic initiation for patients in sepsis phase with higher severity scores was associated with significant improvement in survival rate

Burnout and associated factors among Iranian emergency medicine practitioners

Emergency physicians are at risk of burnout, which can affect their mental health, as well as patient care. We assessed burnout level among Iranian emergency physicians and investigated demographic, work-related factors and stressors associated with higher burnout. In a cross-sectional study, we surveyed all 188 emergency medicine residents and practitioners in Iran. We measured burnout using 22-tiem Maslach Burnout Inventory assessing emotional exhaustion, depersonalization and personal accomplishment, also demographic factors, work related factors and sources of stress in emergency department using anonymous self-administered questionnaire. Descriptive analysis, univariate analysis to evaluate association with higher score of burnout, and multivariate logistic regression analysis to predict high burnout in 3 subscales was performed. Totally 165 questionnaires were filled [response rate: 88%; mean age: 33.6 years, 91% male]. Mean burnout scores were 22.94 for emotional exhaustion [95% CI=20.78-25.01; moderate], 93 for depersonalization [95% CI=8.24-10.36; moderate to high], and 31.47 for personal accomplishment [95% CI=29.87-33.07; moderate to high]. Frequent reported sources of stress were shortage of equipment, problem with work physical environment, and relationship with other services. All 19 sources of stress were associated with higher score of emotional exhaustion and depersonalization; while twelve out of 19 were significantly associated with lower level of personal accomplishment. In logistic regression model, the significant predictors for high emotional exhaustion were work overload, feeling of insecurity for future career and difficulties to balance professional and private life. Burnout is high among Iranian emergency medicine practitioners and some interventions can be proposed to reduce stress

Identifying causes of laboratory turnaround time delay in the emergency department

Laboratory turnaround time [TAT] is an important determinant of patient stay and quality of care. Our objective is to evaluate laboratory TAT in our emergency department [ED] and to generate a simple model for identifying the primary causes for delay. We measured TATs of hemoglobin, potassium, and prothrombin time tests requested in the ED of a tertiary-care, metropolitan hospital during a consecutive one-week period. The time of different steps [physician order, nurse registration, blood-draw, specimen dispatch from the ED, specimen arrival at the laboratory, and result availability] in the test turnaround process were recorded and the intervals between these steps [order processing, specimen collection, ED waiting, transit, and within-laboratory time] and total TAT were calculated. Median TATs for hemoglobin and potassium were compared with those of the 1990 Q-Probes Study [25min for hemoglobin and 36 min for potassium] and its recommended goals [45 min for 90% of tests]. intervals were compared according to the proportion of TAT they comprised. Median TATs [170 min for 132 homoglobin tests, 225 min for 172 potassium tests, and 195.5 min for 128 prothrombin tests] were drastically longer than Q-Probes reported and recommended TATs. The longest intervals were ED waiting ime and order processing. Laboratory TAT varies among institutions, and data are sparse in developing countries. In our Ed, actions to reduce Ed waiting time and order processing are top priorities. We recommend utilization of this model by other institutions in setting with limited resources to identify their own priorities for reducing laboratory TAT

Comparison of two methods of teaching hypertension in under graduate medical students: [planned lecture] versus [cooperative learning]

The direct and indirect negative impacts of hypertension on mortality and morbidity and the deficiencies in physicians' knowledge on its management prompted us to search for new methods of training this item. In this study, 2 methods of teaching-planned lecture and cooperation were compared in instructing hypertension to medical students. This study was designed to be a prospective analysis of the efficacy of 2 models of cooperation and planned lecture teaching of hypertension. The medical students, in the second term of the 2010 academic year who were introduced to the nephrology ward for their internal medicine course, were randomly assigned to 2 groups to be taught hypertension by 2 models of cooperation and planned lecture to compare their ad-; vantages and disadvantages. In their final exam 2 questions concerning the management of hypertension were asked with regard to evaluating the long-term impact of the models on learning. Data were analyzed by paired t-test to compare pre-and post-test in each group, and independent t-test was used to compare the average and standard deviation scores between groups. Fifty-one students participated in the study. The total number of students in the lecture [group 1] and cooperation [group 2] methods was 28 and 23, respectively. By independent t-test, differences in test scores indicated a similar achievement of the 2 methods for the endpoint of basic knowledge [P = 0.253]. But, the cooperation method was more successful in transferring abilities, primarily in the areas of workup and treatment [P < 0.05]. The study findings show that both methods can set in the optimal training for hypertension to students but that the cooperative method is more effective for deduction analysis

Development of the emergency medicine curriculum at the national level: another forward step toward establishment of emergency medicine in Iran

Emergency Medicine [EM] in Iran is a young specialty. As one of the steps taken towards the establishment of EM, a National Curriculum has been developed for residency programs. The curriculum is based on current concepts in medical education and aims at ensuring that all EM residencies in Iran provide for the acquisition of pre-defined core competencies by trainees. The curriculum has been organized into a format that can be easily communicated to all stakeholders. This article describes the process of EM residency curriculum planning in Iran as an example for other countries, in the early stages of developing EM training, to consider

A survey of medical students' perceptions of the quality of their medical education upon graduation

<p><b>INTRODUCTION</b>To evaluate the perceptions of the graduates of our medical school regarding the quality of their educational programme.</p><p><b>MATERIALS AND METHODS</b>A total of 183 questionnaires, each containing 262 questions, were completed anonymously by medical students upon their graduation from the medical school.</p><p><b>RESULTS</b>About 77% of the respondents felt that Basic Science courses lacked clinical relevance. Many of the students (61.2%) believed that physiology, amongst other Basic Science courses, was the most clinically relevant course. Assessment of the students about their clinical clerkship and internship rotations was not very favourable. Overall only 28.4% of the respondents were generally satisfied with the medical training they received. Respondents indicated many deficiencies in the curriculum, and in their competences. Exposure to numerous activities was rated by respondents as being inadequate: "geriatrics and gerontology education" (87.5%), "office management" (86.4%), "alternative medicine" (85.8%), "healthcare quality improvement" (85.7%), and "rehabilitation" (83%). Around 70% of the respondents reported that they have not been taught sufficient clinical skills in preparations for their future clinical practice. Only 33.3% of the respondents felt that they had acquired adequate knowledge and skills to start residency training.</p><p><b>CONCLUSIONS</b>This study illuminates many aspects of the curriculum the faculty needs to address in order to prepare physicians effectively and efficiently for clinical work. It can be used as a tool to find the trends in our curriculum and the impact of curriculum revision activities which are currently underway in our School of Medicine.</p>