Multiple Sleep Latency Test: when are 4 naps enough?

STUDY OBJECTIVES: The Multiple Sleep Latency Test (MSLT) is central to the diagnosis of narcolepsy and idiopathic hypersomnia. This study is the first to assess the impact of a 5-nap protocol on meeting MSLT-derived diagnostic criteria in a general cohort referred for MSLT, without selection bias. METHODS: Data for all MSLTs performed at 2 tertiary sleep units in Australia between May 2012 and May 2018 were retrospectively assessed for the impact of the fifth nap on mean sleep latency (MSL) and sleep onset rapid eye movement periods. RESULTS: There were 122 MSLTs included. The MSL was 8.7 ± 5.1 minutes after 4 naps, compared with 9.2 ± 5.2 minutes for 5 naps (P < .0001). In 8 cases, inclusion of the fifth nap changed the MSL to a value above the diagnostic threshold of 8 minutes. There were no instances in which the MSL moved to ≤ 8 minutes based on fifth nap data. A sleep onset rapid eye movement period occurred in the fifth nap in 9 patients and altered the interpretation in 2 cases. CONCLUSIONS: The fifth nap in an MSLT is associated with an increased MSL, although this difference is rarely clinically significant. In patients with borderline MSL or 1 sleep onset rapid eye movement period after 4 naps, a fifth nap can alter the outcome and should be performed. However, for many cases, a 4-nap MSLT protocol will suffice, potentially allowing resource savings without compromising diagnostic accuracy. We propose the adoption of a conditional 4-nap or 5-nap protocol based on specific criteria.

Adding random case analysis to direct observation (ARCADO) - Updating the external clinical teaching visit to improve general practice registrar assessments.

BACKGROUND: In response to the advent of competency-based training and the increase in the number of general practice registrars, the Australian general practice education community is seeking valid, reliable, time-efficient and cost-efficient tools to assess registrars. Despite the central role of the external clinical teaching visit (ECTV) in formative assessment of general practice registrars, the ECTV has been an infrequent subject of research or evaluation. OBJECTIVE: The objective of this article is to report on the development of a new approach to ECTV that adds random case analysis to direct observation of consultations - ARCADO ECTV. DISCUSSION: ARCADO ECTV is a flexible, acceptable and time-efficient formative assessment. The two assessment approaches in the ARCADO ECTV provide complementary insights into the registrar's performance. At least three observed consultations are required to ensure adequate assessment of communications skills. Medical records need to be of recent consultations. There is scope for development of the ARCADO ECTV as a summative assessment.

A blended supervision model in Australian general practice training.

BACKGROUND: The Royal Australian College of General Practitioners' Standards for general practice training allow different models of registrar supervision, provided these models achieve the outcomes of facilitating registrars' learning and ensuring patient safety. OBJECTIVE: In this article, we describe a model of supervision called 'blended supervision', and its initial implementation and evaluation. DISCUSSION: The blended supervision model integrates offsite supervision with available local supervision resources. It is a pragmatic alternative to traditional supervision. Further evaluation of the cost-effectiveness, safety and effectiveness of this model is required, as is the recruitment and training of remote supervisors. A framework of questions was developed to outline the training practice's supervision methods and explain how blended supervision is achieving supervision and teaching outcomes. The supervision and teaching framework can be used to understand the supervision methods of all practices, not just practices using blended supervision.

ARCADO - Adding random case analysis to direct observation in workplace-based formative assessment of general practice registrars.

BACKGROUND: Workplace-based formative assessments using consultation observation are currently conducted during the Australian general practice training program. Assessment reliability is improved by using multiple assessment methods. The aim of this study was to explore experiences of general practice medical educator assessors and registrars (trainees) when adding random case analysis to direct observation (ARCADO) during formative workplace-based assessments. METHODS: A sample of general practice medical educators and matched registrars were recruited. Following the ARCADO workplace assessment, semi-structured qualitative interviews were conducted. The data was analysed thematically. RESULTS: Ten registrars and eight medical educators participated. Four major themes emerged - formative versus summative assessment; strengths (acceptability, flexibility, time efficiency, complementarity and authenticity); weaknesses (reduced observation and integrity risks); and contextual factors (variation in assessment content, assessment timing, registrar-medical educator relationship, medical educator's approach and registrar ability). CONCLUSION: ARCADO is a well-accepted workplace-based formative assessment perceived by registrars and assessors to be valid and flexible. The use of ARCADO enabled complementary insights that would not have been achieved with direct observation alone. Whilst there are some contextual factors to be considered in its implementation, ARCADO appears to have utility as formative assessment and, subject to further evaluation, high-stakes assessment.

Why and how do general practitioners teach? An exploration of the motivations and experiences of rural Australian general practitioner supervisors.

BACKGROUND: In medical education, a learner-centred approach is recommended. There is also a trend towards workplace-based learning outside of the hospital setting. In Australia, this has resulted in an increased need for General Practitioner (GP) supervisors who are receptive to using adult learning principles in their teaching. Little is known about what motivates Australian GP supervisors and how they currently teach. METHODS: A qualitative study involving semi-structured interviews with 20 rural GP supervisors who work within one Regional Training Provider region in Australia explored their reasons for being a supervisor and how they performed their role. Data was analysed using a thematic analysis approach. RESULTS: GP supervisors identified both personal and professional benefits in being a supervisor, as well as some benefits for their practice. Supervision fulfilled a perceived broader responsibility to the profession and community, though they felt it had little impact on rural retention of doctors. While financial issues did not provide significant motivation to teach, the increasing financial inequity compared with providing direct patient care might impact negatively on the decision to be or to remain a supervisor in the future. The principal challenge for supervisors was finding time for teaching. Despite this, there was little evidence of supervisors adopting strategies to reduce teaching load. Teaching methods were reported in the majority to be case-based with styles extending from didactic to coach/facilitator. The two-way collegiate relationship with a registrar was valued, with supervisors taking an interest in the registrars beyond their development as a clinician. CONCLUSION: Supervisors report positively on their teaching and mentoring roles. Recruitment strategies that highlight the personal and professional benefits that supervision offers are needed. Practices need assistance to adopt models of supervision and teaching that will help supervisors productively manage the increasing number of learners in their practices. Educational institutions should facilitate the development and maintenance of supportive supervision and a learning culture within teaching practices. Given the variety of teaching approaches, evaluation of in-practice teaching is recommended.

Are GP supervisors confident they can assess registrar competence and safety, and what methods do they use?

BACKGROUND: The new Royal Australian College of General Practitioners' vocational training standards emphasise patient safety and matching the level of supervision to registrar competence. METHODS: All supervisors attending a regional training provider's annual education workshop were surveyed about their overall confidence in assessing the safety of their registrars' patients, their registrars' competence across the five RACGP domains of general practice and supervision methods used. RESULTS: Of 84 supervisors, 92.8% expressed overall confidence in their ability to assess their registrars' competence and 10.7% were totally confident. Consultation observation and audit techniques were infrequently used in their assessments. DISCUSSION: Supervisors reported confidence in their ability to assess their registrars' competence, suggesting readiness for outcomes-based standards. The low frequency of using supervision methods considered more effective in targeting registrars' 'unknown unknowns' and the reduction in confidence with greater experiences as a supervisor raises concerns about the accuracy of this self-assessment.

GP supervisors--an investigation into their motivations and teaching activities.

BACKGROUND: There is little empirical information on how general practitioner (GP) supervisors teach and the reasons for the variation in their teaching methods. Could the variation be due to differing motivations to teach? METHODS: Supervisors from one regional training provider who attended educational workshops in 2013 were surveyed, seeking infor-mation on their motivation to become and remain a supervisor, and the frequency of use of selected teaching activities. RESULTS: The majority of respondents cited intrinsic motivators, including enjoying teaching (84%), contribution to the profession and community (82%), adding variety (78%) and workforce/succession planning (69%), as reasons for becoming GP supervisors. The expected relationships between motivations and teaching activities were not found. DISCUSSION: Variation in teaching activities used by supervisors does not appear to be associated with differing motivations. Measuring the use of teaching activities is not a mechanism to determine a supervisor's commitment to teaching.