Implementing the CanMEDSTM physician roles in rural specialist education: the Multi-Speciality Community Training Network.

CONTEXT: Changing medical education to realign it with societal needs has become a renewed priority in many countries. Advanced training in rural settings to prepare physicians to better serve rural areas has received particular attention around the world. Such initiatives are usually targeted at primary care practitioners. Few initiatives have been designed to enhance specialist training in a rural setting, let alone adapt specialist competency frameworks such as the CanMEDSTM roles of the Royal College of Physicians and Surgeons of Canada to non-urban medical education. ISSUE: We describe an innovation in medical training for rural competence for specialist physicians using the CanMEDS framework near London, Ontario, Canada. Since 1997, the University of Western Ontario has established its Multi-Specialty Community Training Network (MSCTN) to provide rural and regional training opportunities for specialty residents in anaesthesia, general surgery, internal medicine, paediatrics, obstetrics and psychiatry. It became the first program in Canada to fully adapt the new CanMEDS roles into learning objectives and evaluations. LESSONS LEARNED: Competency-based frameworks like CanMEDS are important because they provide a comprehensive tool to organize outcome-based curricula. The CanMEDS roles framework has been very useful in developing educational goals for rural/regional specialty resident rotations as well as forming a constructive basis for resident, preceptor, and program evaluations. Our experiences with this program may provide lessons for others planning training for specialists in rural settings, and those adopting the CanMEDS competency framework.

Transplantation of Descemet's membrane carrying viable endothelium through a small scleral incision.

PURPOSE: To design a technique for transplantation of the Descemet's membrane (DM) as a carrier for its endothelium, while maintaining the low-astigmatic recipient anterior corneal curvature. METHODS: In a human eye bank eye model, recipient eyes (n = 15) had a 5.0-mm scleral tunnel incision made, extending 1.0 mm into the peripheral cornea. A 9.0-mm-diameter Descemeto rhexis was created, i.e., a circular portion of DM was stripped from the posterior stroma. With use of a custom-made inserter, a 9.0-mm-diameter donor DM carrying autologous donor endothelium was brought into the anterior chamber and positioned against the recipient posterior stroma. The procedure was evaluated by keratometry, endothelial vital and supravital staining, and light microscopy. RESULTS: Mean postoperative astigmatism was 1.0 D (+/-0.6 D). Implanted donor DM showed an intact endothelial cell layer, with 3.4% (+/-1.1%) dispersed focal cell death. Microscopy showed normal endothelial cell morphology and complete apposition of the donor DM against the recipient posterior stroma. CONCLUSIONS: DM can be transplanted in vitro with acceptable damage to the donor endothelium and with little induced astigmatism.

Educating future physicians for Ontario: phase II.

In 1990, a collaborative project was launched to determine what the people of Ontario expect of their physicians and how the programs that prepare future physicians should be changed in response. The project, called Educating Future Physicians for Ontario (EFPO), brought together the five Ontario medical schools, the Council of Ontario Faculties of Medicine (COFM); a nonprofit, charitable organization, Associated Medical Services (AMS); and the Ontario Ministry of Health. The first phase ran for five years and was described in the November 1998 issue of Academic Medicine. After an external review, the project was continued for a second phase (EFPO II) for four more years until December 1998; that second phase is the topic of this article. EFPO II (1) focused more on residents' education; (2) emphasized four of the EFPO I-created physician roles in project activities; (3) maintained the province-wide, inter-institutional medical education framework of phase I, but fostered greater involvement of the seven sites (five medical schools and two regional health centers) in project activities; (4) stressed five project components (e.g., needs assessment and community partnerships) and worked for collaboration among components at all sites; (5) enhanced the original EFPO I Fellowship Program by adding residents and community fellows to the existing fellowships and by initiating leadership development activities, all of which bode well for the future leadership of medical education in Ontario. Students and residents played a vital role in EPFO II. Most of EFPO II's objectives were met, but the overall view of external reviewers was that the project was less successful than EFPO I. For example, the impact on clinical education, especially residency education, was less than anticipated. On the other hand, the project helped encourage the wide adoption of the eight physician roles that originated in EFPO I and advanced faculty development and assessment activities based on these roles. A third phase of EFPO concerning continuing medical education was planned, but support was not available. However, one of the funders will continue to support the successful fellowship and leadership program and the provincial education network for the next three years. Overall, the two phases of EFPO substantially modified medical education in Ontario to make it more responsive to evolving social needs.

A retrospective study of ehrlichiosis in 62 dogs from North Carolina and Virginia.

The purpose of this retrospective study is to report the clinical signs, clinicopathological findings, and response to therapy of 62 dogs from North Carolina and Virginia. Ehrlichiosis was diagnosed in all of these dogs, and previous retrospective studies of ehrlichiosis in dogs were used as a basis for comparison. In this study, the clinical signs commonly associated with ehrlichiosis were observed less frequently than in earlier studies, although previously reported laboratory abnormalities were similar. Flow cytometry revealed an inverted CD4:CD8 ratio in 3 of 4 dogs tested. This finding is suggestive of potential immune dysregulation that could predispose infected dogs to additional disease processes. Concurrent diseases were frequently reported and often contributed to death. Response to therapy was variable, with timely, complete recovery reported in only 27% of dogs; a slow, gradual, but complete recovery in 18% of dogs; an incomplete treatment response in 25% of dogs; and a presumed treatment failure in 16% of dogs.

Systemic arterial dirofilariasis in five dogs.

Systemic arterial dirofilariasis is an unusual manifestation of heartworm disease of dogs that results from aberrant migration of Dirofilaria immitis into the peripheral arterial circulation. To expand the clinical characterization of systemic arterial dirofilariasis, 5 dogs evaluated at the North Carolina State University's College of Veterinary Medicine were reviewed. Common clinical presentations included hindlimb lameness, paresthesia of hindlimbs, and interdigital ischemic necrosis resulting from thromboembolic disease. Visualization of heartworms with angiography or ultrasonography confirmed the diagnosis in all cases. All 5 dogs were treated with an adulticide; 3 dogs were treated with thiacetasamide sodium and 2 with melarsomine dihydrochloride. Four of the 5 dogs survived the initial treatment period; 1 dog died of severe thromboembolic complications after thiacatarsamide sodium therapy. The treatment of systemic arterial dirofilariasis creates a therapeutic challenge because of multiple potential complications resulting from thromboembolic disease.