New beginnings in post graduate medical education. Latin American Medical Education Leaders Forum / Nuevos comienzos en la educación médica de postgrado. Foro Latinoamericano de Líderes en Educación Médica

Introduction: The consequences of the Covid-19 epidemic have been catastrophic for Latin America in 2021. This study explores experiences, lessons learned, and practice changes during this critical time in post-graduate medical education in Latin America. Me-thods: A panel of 53 post-graduate medical education leaders from 8 Latin American countries and Canada was invited to participate in the 2021 Latin American Medical Education Leaders Forum to share their experiences, lessons learned, and main educational practice changes given the Covid-19 pandemic scenario. Participants were selected following a snowball technique with the goal of obtaining a diverse group of experts. Small group discussions were conducted by bilingual facilitators based on a semi-structured questionnaire. The plenary session with the main conclusions of each group was recorded and fully transcribed for a thematic analysis using a framework methods approach. Results: Participants ́ profiles included 13 experienced clinician-educators, 19 program directors, and 23 deans or organizational representatives. Seven specific themes emerged. They followed a pattern that went from an initial emotional reaction of surprise to a complex collective response. The responses highlighted the value of adaptability, the application of new digital skills, a renovated residents' protagonism, the strengthening of humanism in medicine, the openness of new perspectives in wellness, and finally, an unresolved challenge of assessment in medical education in a virtual post-pandemic scenario. Conclusion: A diverse panel of medical educators from Latin America and Canada identified changes triggered by the Covid-19 pandemic that could transform postgraduate medical education in the region.

Introducción: la pandemia de Covid-19 ha tenido consecuencias catastróficas para América Latina en el año 2021. Este estudio explora las experiencias, lecciones aprendidas y nuevas prácticas surgidas durante este crítico período en la educación médica de postgrado en América Latina. Métodos: un panel de 53 líderes de 8 países de América Latina y Canadá fue invitado a participar en el Foro Latinoame-ricano de Líderes en Educación Médica 2021 para compartir sus experiencias, lecciones aprendidas y cambios de prácticas educativas en el escenario de pandemia. Los participantes fueron seleccionados mediante la técnica de bola de nieve con el objetivo de obtener un grupo diverso de expertos. El Foro incluyó discusiones de pequeños grupos conducidos por facilitadores bilingües basadas en un cuestionario semiestructurado. La sesión plenaria con las principales conclusiones de los grupos fue grabada y transcrita para el análisis temático posterior utilizando la metodología de marco analítico. Resultados: el perfil de participantes incluyó 13 experimentados edu-cadores, 19 directores de programa y 23 decanos o representantes institucionales. Siete tópicos emergieron durante la discusión. Ellos siguieron un patrón que transitó desde una reacción emocional de sorpresa por la pandemia hasta una respuesta colectiva compleja. Las respuestas enfatizaron el valor de la adaptabilidad, la aplicación de nuevas habilidades digitales, un renovado protagonismo de los residentes, el fortalecimiento del humanismo en medicina, la apertura a nuevas perspectivas de bienestar y, finalmente, un desafío no resuelto respecto de la evaluación en educación médica en escenarios de pandemia. Conclusión: un panel diverso de educadores médicos latinoamericanos y canadienses identificó cambios claves gatillados por la pandemia de Covid-19 que pueden transformar la educación médica de postgrado en la región.

Burnout en la formación de profesionales de la salud en Chile: factores de protección y riesgo, y propuestas de abordaje desde la perspectiva de los educadores / Burnout in students of health-care professions: risk and protection factors

Background: The burnout syndrome affects more than half of students and professionals involved in healthcare worldwide and is characterized by emotional exhaustion, depersonalization and a low perception of self-efficacy. Several studies indicate that when students are burnt-out, clinical work, professionalism and ethical behavior, as well as empathy, are negatively affected, while the risk of academic attrition, depression and suicidal ideation tend to increase. At a national level, recent information shows that one out of every two medical students suffer burnout at the beginning of the clinical cycle, a situation that does not improve after finishing undergraduate medical training. There is no consensus on which are the most appropriate strategies to face the problem of burnout in students and health-care professionals. Some studies indicate that the experience of medical and health educators may be key to the design of effective strategies to address this problem. Aim: To identify the burnout risk and protection factors of students at different medical schools. Material and Methods: In this study -in which 34 expert health educators from eight Chilean medical schools and other health-related schools participated- we used a qualitative methodology based on the appreciative inquiry to explore the key elements associated with the occurrence of burnout, identify protective and risk factors, as well as discuss possible effective interventions to prevent it. Results: There are personal, academic and contextual elements that act as protective or risk factors of burnout. In addition, the educators identified key elements to design organizational and curricular interventions to face the problem of burnout at a local level. Conclusions: Burnout is a serious problem in the formation of health care professionals. Teacher training aimed at promoting student'well-being must include the teaching of communication skills that consider both the generation gap and the profile of the professional medical schools intend to form.

Acceso a colecistectomía en un programa de tamizaje ecográfico de colelitiasis en centros de medicina familiar / Access to cholecystectomy among patients attended at primary family health centers

Background: Cholelithiasis (CL) represents a major health burden in Chile, with rates of cholecystectomy (CCT) of ~40.000 per year. The explicit health care guaranties (GES) program includes prioritized CCT for CL carriers between 35 and 49 years of age. Aim: To assess the access and opportunity of CCT in a screening program of CL in Family Medicine Centers, according to the age of the patients. Material and Methods: A systematic ultrasound screening program of CL was developed in Family Medicine Centers ANCORA-UC between March 2009 and March 2013 during which 1.450 individuals were assessed, (80% women) and 281 were identified as having CL (19.4%). After a minimum follow up interval of six months, patients with CL were contacted and surveyed by phone. They were categorized as being beneficiaries of the GES program (those aged between 35 to 49 years) or not (those aged < 35 o > 49 years). Results: Two hundred thirteen patients were contacted (76%), 81 beneficiaries of the program and 132 non-beneficiaries. The attending physician indicated CCT to 191 patients (89.6%). During a mean follow-up time of 641 days/person, 100 patients had CCT, 11% of which were emergency interventions due to complications. A greater proportion of program beneficiaries than non-beneficiaries had an elective CCT (74 and 21% respectively). The waiting interval for elective CCT was longer in non-beneficiaries compared with beneficiaries (340 ± 247 and 229 ± 201 days respectively). Only 46% of the elective CCT in GES patients were done within deadlines determined by the program (≤ 150 days). Conclusions: The age of patients at the moment of CL diagnosis conditions the access and opportunity to CCT. Beneficiaries of the explicit health care guaranties program have higher rates of cholecystectomy with less waiting time.

HPV vaginal self-sampling among women non-adherent to Papanicolaou screening in Chile / Autotoma vaginal para detección de virus del papiloma humano en mujeres no adherentes a tamizaje con Papanicolaou en Chile

OBJECTIVE: To evaluate acceptance, preference and compliance with referral of vaginal self-sampling for the detection of Human papillomavirus (HPV) among women non-adherent to Papanicolaou (Pap) screening in Santiago, Chile. MATERIALS AND METHODS: Using multistage sampling we identified women aged 30-64 years who reported not receiving a Pap test in the previous three years and offered them Pap testing at the health center or vaginal self-sampling for HPV testing at home. Self-collected samples were analyzed with hybrid capture. All HPV+ women were referred for colposcopy, biopsy and treatment when needed. RESULTS: 1 254 eligible women were contacted; 86.5% performed self-sampling and 8.1% refused; 124 women were HPV+ (11.4%: 95%CI 9.6-13.5) of whom 85.5% attended colposcopy; 12 had CIN2+ (1.1%: 95 %CI 0.5-1.7). CONCLUSION: HPV vaginal self-sampling can be easily implemented in Chile and could improve coverage, successfully reaching women who drop out of the screening program.

OBJETIVO: Evaluar la aceptación, preferencia y adherencia a seguimiento de la autotoma vaginal para detección del virus del papiloma humano (VPH) en mujeres inasistentes a Papanicolaou (Pap) en Santiago, Chile. MATERIAL Y MÉTODOS: Mediante un muestreo polietápico se identificaron mujeres entre 30 y 64 años inasistentes a Pap por < 3 años, invitándolas a realizarse un Pap en su centro de salud o una autotoma vaginal a domicilio. Las muestras fueron analizadas con captura de híbridos. Las mujeres VPH+ fueron referidas a colposcopía, biopsia y tratamiento en caso necesario. RESULTADOS: 1 254 mujeres elegibles fueron contactadas; 86.5% aceptó la autotoma vaginal y 8.1% la rechazó; 124 mujeres resultaron VPH+ (11.4%: IC95% 9.6-13.5) de las que 85.5% asistió a colposcopía; 12 tenían CIN2+ (1.1%: IC95% 0.5-1.7). CONCLUSIÓN: La autotoma vaginal para detección de VPH es implementable en Chile y su utilización podría mejorar la cobertura del programa rescatando a mujeres inasistentes.

Diseño y validación del instrumento SALUFAM: un instrumento de valoración de la salud familiar con alto valor predictivo clínico para la atención primaria chilena / Design and validation of an instrument to assess families at risk for health problems

Background: There is a paucity of screening instruments with a high clinical predictive value to identify families at risk and therefore, develop focused interventions in primary care. Aim: To develop an easy to apply screening instrument with a high clinical predictive value to identify families with a higher health vulnerability. Material and Methods: In the first stage of the study an instrument with a high content validity was designed through a review of existent instruments, qualitative interviews with families and expert opinions following a Delphi approach of three rounds. In the second stage, concurrent validity was tested through a comparative analysis between the pilot instrument and a family clinical interview conducted to 300families randomly selected from a population registered at a primary care clinic in Santiago. The sampling was blocked based on the presence of diabetes, depression, child asthma, behavioral disorders, presence of an older person or the lack of previous conditions among family members. The third stage, was directed to test the clinical predictive validity of the instrument by comparing the baseline vulnerability obtained by the instrument and the change in clinical status and health related quality of life perceptions of the family members after nine months of follow-up. Results: The final SALUFAM instrument included 13 items and had a high internal consistency (Cronbach's alpha: 0.821), high test re-test reproducibility (Pearson correlation: 0.84) and a high clinical predictive value for clinical deterioration (Odds ratio: 1.826; 95% confidence intervals: 1.101-3.029). Conclusions: SALUFAM instrument is applicable, replicable, has a high content validity, concurrent validity and clinical predictive value.

Factores de riesgo de alteraciones citológicas del cuello uterino en mujeres chilenas: Un estudio de casos y controles / Risk factors associated with abnormal cervical cytology among Chilean women: A case control study

Background: Cervical cancer is the third cause of cancer death among Chilean women, affecting mainly women from low socioeconomic status. Aim: To determine main risk factors (RF) including human papilomavirus (HPV) types associated with abnormal cervical cytology (Atypical Squamous Cells of Undetermined Significance or ASCUS) among Chilean women from low socioeconomic status in Santiago, Chile. Material and Methods: A random population based sample of616 women from La Pintana (a low-income district in Santiago) participated in 2001 in a HPV prevalence study and were re-evaluated in 2006 through a risk factors questionnaire, Papanicolaou test and DNA detection for HPV. The Papanicolaou test was analyzed in Santiago and HPV analysis (PCR_GP5+/GP6+) was conducted in Vrije University, Amsterdam. Cases included 42 women with cervical lesions and controls included 574 women with normal cytology during the period 2001-2006. Logistic regression with uni and multivariate analysis was performed to identify RF for cervical lesions. Results: During the study period, there was a significant increase in the proportion of single women, from 8.3 to 14.8 percent (p < 0.05), of women with 3 or more sexual partners from 8.9 to 13.3 and of women high risk HPV, from 9.1 to 14.3 percent. The proportion of abnormal Papanicolaou tests remained stable (3.08 and 3.9 percent > ASCUS). High risk HPV was the most significant factor associated with cervical lesions (odds ratio (OR) = 9.695 percent> confidence intervals (CI) = 4.4-21.1) followed by oral contraceptive use (OR = 2.58 95 percent> CI= 1.2-5.7). Among women infected by high risk HPV, the use of oral contraceptives was a risk factor while compliance with screening was protective for cervical lesions. Conclusions: From 2001 to 2006, there was an increase in the proportion of women with high-risk HPV infections.

Factores predictores de inicio y cesación de tabaquismo en una cohorte de mujeres chilenas con 5, 5 años de seguimiento / Predictive factors for smoking initiation and quitting among a cohort of Chilean women followed for 5.5 years

Background: Chilean women have one of the highest smoking prevalence in the world. Aim To estimate the main factors associated with smoking initiation and quitting among a cohort of adult women living in a low socioeconomic status area of Santiago, Chile. Material and methods: A random population-based sample of 1,100 women, 18 years and older, were selected from a community located in the South East area of Santiago. Sociodemographic, as well as smoking, beliefs, behaviors, stages of change and nicotine addiction level were recorded during a personal interview. After an average follow-up period of 5.5years, women were re-evaluated. Results: Seventy-three percent of women completed the study. At baseline, 39 percent of women were smokers. At the end of the study, there was an absolute smoking rate reduction of 7.1 percent (p <0.001). The main variables associated with smoking initiation were younger age (Odds ratio (OR): 1.08, 95 percent confidence intervals (CI): 1.05-1.12), higher education level (OR: 1.2, 95 percent CI: 1.07-1.35), and having fewer children (OR: 1.3 95 percent CI: 1.01-1.66). Factors related with quitting were younger age of onset (OR: 1.06 95 percent CI: 1.02-1.1), higher level of nicotine dependence (OR: 4.22, 95 percent CI: 1.74-10.27), and higher perception of smoking addiction (OR: 4.34, 95 percent CI: 2-9.09). Stage of change was associated with smoking cessation but its effect was diluted after adjusting for the level of nicotine addiction. Conclusions: Sociodemographic and family factors were the main variables related with initiation, whereas age of onset, belief of addiction, and nicotine dependence were the main factors related with cessation. Women with a high motivation for quitting should be evaluated for nicotine addiction level to define the best strategy for intervention.

Morbimortalidad asociada a bloqueo auriculoventricular en el infarto del miocardio de pared inferior / Morbidity and mortality in atriventricular block of acute inferior wall myocardial infarction

El infarto del miocardio (IAM) de pared inferior, complicado con bloqueo auriculoventricular (BAV) se asocia a mayor mortalidad a pesar de ser en muchos casos transitorio. Con el objeto de analizar las causas de esta mayor mortallidad se estudiaron 307 pacientes (pts) consecutivos con IAM inferior, dividiéndolos en 421 pts sin BAV (grupo I) y 66 pts con BAV de 2o. ó 3o. grado (grupo II). La mortalidad global fue 10.7 (8.3% grupo I, p<0.001). No encontramos diferencias en ambos grupos respecto a factores de riesgo (excepto para tabaquismo, que fué mayor en el grupo I, p<0.001), antecedente de IAM, angina crónica o insuficiencia cardíaca previa. Encontramos diferencias significativas en ambos grupos respecto a edad (61 ñ 12 grupos I vs 68 ñ 9 años grupo 2, p<0.001) y en niveles máximos de CPK x ñ DS (1513 ñ 1135 grupo I vs 1958 ñ 1293 UI/1 grupo II, p<0.01). Durante su evolución los pacientes del grupo II presentaron mayor incidencia de arritmias ventriculares complejas, (p<0.01), de arritmias supraventriculares p<0.01) y de insuficiencia cardíaca Killip III y IV, (p<0.0001). Se estudiaron 123 pts con coronariografía, 106 del grupo I y 17 pts del grupo II. En los pts con BAV se encontró mayor incidencia de enfermedad de 3 arterias (47% vs 28%) y de lesiones críticas asociadas de arterias descendente anterior y derecha (29% vs 12%, p<0.06). En conclusión, los pts con IAM inferior complicado de BAV tienen mayor mortalidad en relación a edad más avanzada, necrosis más extensa, más complicaciones asociadas, y mayor incidencia de lesiones asociadas de arterias descendente anterior y derecha