The "Culture OSCE"--introducing a formative assessment into a postgraduate program.

BACKGROUND: There is a growing need for appropriate training models in the area of cultural competence. An Objective Structured Clinical Exam (OSCE) format is ideal for this endeavor, since it allows for skills practice and feedback. As a result, we designed the first formative Culture OSCE at Maimonides Medical Center and have been implementing it since 1999. PROGRAM DEVELOPMENT: An interdisciplinary committee developed the OSCE as a formative assessment. Stations were designed based on a review of the literature and real situations experienced in the hospital. A two-hour workshop introducing the concept of cultural competence precedes the OSCE. The emphasis is on skills that are generalizable to encounters with any culture. Standardized patients are recruited from the relevant cultural groups or are trained to understand specific cultural issues. Costumes and props are utilized to enhance the authenticity of the encounter. Faculty, recruited and trained to observe encounters, gives constructive feedback, thus enhancing faculty development in this area as well. A rating scale was developed which incorporates communication and cultural skills as two separate dimensions of the encounter. PROGRAM EVALUATION: Written feedback is obtained from residents, the trained faculty observers and the standardized patients. Resident feedback has demonstrated good face validity. A post-OSCE debriefing session allows residents an opportunity to consolidate learning and give oral feedback. CONCLUSION: The Maimonides Medical Center Pediatrics Department designed the first Culture OSCE. This is deemed to be a valuable training tool, and serves to highlight the importance of cultural competence within the Department.

A randomized trial of teaching clinical skills using virtual and live standardized patients.

BACKGROUND: We developed computer-based virtual patient (VP) cases to complement an interactive continuing medical education (CME) course that emphasizes skills practice using standardized patients (SP). Virtual patient simulations have the significant advantages of requiring fewer personnel and resources, being accessible at any time, and being highly standardized. Little is known about the educational effectiveness of these new resources. We conducted a randomized trial to assess the educational effectiveness of VPs and SPs in teaching clinical skills. OBJECTIVE: To determine the effectiveness of VP cases when compared with live SP cases in improving clinical skills and knowledge. DESIGN: Randomized trial. PARTICIPANTS: Fifty-five health care providers (registered nurses 45%, physicians 15%, other provider types 40%) who attended a CME program. INTERVENTIONS: Participants were randomized to receive either 4 live cases (n=32) or 2 live and 2 virtual cases (n=23). Other aspects of the course were identical for both groups. RESULTS: Participants in both groups were equivalent with respect to pre-post workshop improvement in comfort level (P=.66) and preparedness to respond (P=.61), to screen (P=.79), and to care (P=.055) for patients using the skills taught. There was no difference in subjective ratings of effectiveness of the VPs and SPs by participants who experienced both (P=.79). Improvement in diagnostic abilities were equivalent in groups who experienced cases either live or virtually. CONCLUSIONS: Improvements in performance and diagnostic ability were equivalent between the groups and participants rated VP and SP cases equally. Including well-designed VPs has a potentially powerful and efficient place in clinical skills training for practicing health care workers.

Combined endovascular/neurosurgical therapy of blister-like distal internal carotid aneurysms.

OBJECTIVE: To describe a novel therapeutic strategy for the treatment of "blister-like" aneurysms of the distal internal carotid artery (ICA). Direct surgical treatments of these fragile lesions have been associated with generally poor outcomes. METHODS: Two consecutive patients presenting with acute subarachnoid hemorrhage from "blister-like" aneurysms were treated with preliminary balloon occlusion of the ICA, followed by surgical trapping of the ICA beyond the aneurysm. RESULTS: The treatment resulted in complete thrombosis of both aneurysms with no clinical complications. CONCLUSION: This combined endovascular-neurosurgical approach offers a controlled, safer alternative to primary surgical therapy of "blister-like" aneurysms.

Mucopolysaccharidoses and spinal cord compression: case report and review of the literature with implications of bone marrow transplantation.

OBJECTIVE AND IMPORTANCE: We present a patient with mucopolysaccharidosis with spinal cord compression, and we review previously published cases. This is the first published case of a patient with mucopolysaccharidosis with spinal cord compression who has undergone bone marrow transplantation. CLINICAL PRESENTATION: A 2-year-old patient with Hurler syndrome underwent bone marrow transplantation. Although the bone marrow transplantation improved many of the systemic effects of Hurler syndrome, the patient presented at 8 years of age with a cervical myelopathy. Magnetic resonance imaging revealed soft tissue compression of the upper cervical cord. The literature review demonstrates that spastic tetraparesis, secondary to cervical cord compression, is the most common presentation of this subgroup of patients. INTERVENTION: A suboccipital craniectomy and C1-C5 laminectomy and decompression with duraplasty were performed. Pathological examination of compressive soft tissue and lamina was consistent with mucopolysaccharidosis. Postoperatively, the patient showed substantial improvement in neurological function. CONCLUSION: Mucopolysaccharidoses can induce a compressive "metabolic myelopathy." Decompressive procedures have shown significant improvement in neurological function in the majority of patients without spinal instability. Bone marrow transplantation may allow more patients with mucopolysaccharidoses to survive long enough to require neurosurgical treatment in the future. The effect of bone marrow transplantation on the prevention of spinal cord compression is unclear.

Educating residents for managed care: report on a multidisciplinary conference.

A growing number of residency programs are preparing their graduates for the realities of managed care practice. In 1996, The Cleveland Clinic Foundation, a private, nonprofit academic medical center, hosted a two-day conference on managed care education to develop innovative instructional and evaluative approaches that, where appropriate, would build on existing expertise. The conference was attended by invited national experts who had a stake in residents' education: clinical faculty, residents, medical educators, executives of managed care organizations, and representatives of other interested organizations. Participants spent much of their time in four small break out groups, each focusing on one of the following topics that were judged particularly relevant to managed care: preventive and population-based medicine, appropriate utilization of resources, clinician-patient communication, and interdisciplinary team practice. Participants shared existing materials, discussed teaching goals and objectives, and generated ideas for teaching methods, teaching materials, and evaluative methods for their respective topics. The authors summarize the recommendations from the four groups, with an overview of the issues that emerged during the conference concerning curriculum development, integration of managed care topics into existing curricula, staging of the curriculum, experiential teaching methods, negative attitudes and resistance, evaluation of trainees and profiling, program assessment, faculty development, and cooperation between academic medical centers and managed care organizations.

Developing models for pediatric residency training in managed care settings.

The preparation of pediatric residents to function optimally in managed care environments challenges educators to create a new set of educational objectives and competencies and to incorporate these into curricula that are already full. Many of the skills needed to practice managed care are those that have been required for the practice of pediatrics in any setting. Nevertheless, the emergence of managed care requires the identification of new knowledge to be acquired and new skills and attitudes to be incorporated into daily practice. These competencies can be identified most thoroughly through collaboration among physicians, educators, and leaders of managed care organizations. This joint effort should also serve to establish a foundation on which collaborative, mutually beneficial learning environments can be created. The development of curricula that provide the opportunities needed to attain managed care proficiencies requires an individualized approach for each program that takes into account the degree of managed care penetration in each training environment. Programs in which a managed care approach to patient care predominates will be able to promote most easily their trainees' incorporation of these principles into routine practice. Those with less regular exposure will be forced either to promote managed care principles in an environment in which they may not be accepted or practiced, or to join in partnership with managed care organizations (MCOs) to train residents. Regardless of the setting, evaluation methodologies must be developed to ensure that each of the core competencies has been learned, can be applied to clinical situations, and is retained throughout the training period. These efforts require the development of faculty who understand and can model a managed care approach to patient management. The ongoing evolution of managed care systems encourages the development of new, creative strategies to train faculty, who may find themselves learning about this emerging environment at the same time as are their trainees.

[Experience with physiotherapy in a posttraumatic neurodystrophic syndrome of the extremities]. / Opyt fizioterapii pri posttravmaticheskom neirodistroficheskom sindrome konechnostei.

Combined pathogenetic treatment including physiotherapy, drugs, massage, exercise was tested in 98 patients with posttraumatic neurodystrophic syndrome in phase II and III. The responses achieved made it possible to recommend the above regimen for wide application in rehabilitation centers and clinics.

ECFMG assessment of clinical competence of graduates of foreign medical schools. Educational Commission for Foreign Medical Graduates.

OBJECTIVE: To develop an assessment of clinical competence of graduates of foreign medical schools and to determine the reliability and validity of the assessment and the feasibility of large-scale administration. DESIGN: The Educational Commission for Foreign Medical Graduates (ECFMG) clinical competence study included (1) clinical encounters with standardized patients to assess history taking, physical examination, and communication skills; (2) laser videodisk pictorials to assess identification and interpretation of diagnostic procedures; (3) written clinical vignettes to assess diagnosis and management skills; and (4) assessment of spoken English. A uniform method of operating the test centers and of training the standardized patients was developed. SETTING: Medical schools and their primary teaching hospitals and affiliated hospitals. PARTICIPANTS: Six hundred twenty-four first-year residents, of whom 525 are graduates of foreign medical schools. MAIN OUTCOME MEASURES: Scores, reliability coefficients, validity measures, feasibility of multisite administration, trends of scores over time, and acceptability by examinees. RESULTS: The ECFMG clinical competence assessment was conducted at four geographically separate test centers. Reliability coefficients were high (.85) for the integrated clinical encounter and were in a reasonable range (.71 to .82) for all test components. The assessment adds to the predictability of the residents' performance in the hospital over that of current ECFMG certification examinations. Test security was addressed by demonstrating no consistent pattern of change in scores over testing dates. Virtually all examinees thought the assessment was appropriate. Standardized patients were able to assess spoken English accurately. CONCLUSION: The feasibility of conducting a reliable and valid test of clinical competence for graduates of foreign medical schools was demonstrated for this test population.

Substance abuse among adolescents with chronic mental illnesses: a pilot study of descriptive and differentiating features.

Twenty-six adolescents with a chronic mental illness (schizophrenia or schizoaffective disorder of at least 1.5 years' duration) were assessed for the presence or absence of comorbid substance abuse. The two groups were compared on a number of variables believed to identify or predict substance abuse. The substance abusing subgroup were significantly different in levels of social functioning, school achievement, premorbid substance abuse, having parents or siblings who abused substances, dysfunctional families, cigarette smoking, number of hospital admissions, and emergency room visits. These findings are discussed in the context of clinical issues regarding the management of adolescents with chronic mental illnesses.

Development of agoraphobia after surviving cancer.

We present a case conference on a 32-year-old accountant who developed embryonal carcinoma of the testis, two months after the birth of a son with a missing leg. His cancer was successfully treated with surgery and chemotherapy. After 5 years, when he was told that he need not be closely followed by his physicians anymore because he had been cured of cancer, he developed agoraphobia with panic attacks. This interfered with his occupational and social adjustment. His phobia was treated successfully with pharmacotherapy, behavior therapy, and psychotherapy. We explore the psychologic impact of cancer, the activation of separation anxiety and aggressive impulses after its successful treatment, the crippling nature of his agoraphobia, and the ingredients of his successful response to treatment.

[Methods of cardiac synchronization in assisted circulation]. / O nekotorykh metodakh kardiosinkhronizatsii pri vspomogatel'nom krovoobrashchenii.

In assisted circulation cardiosynchronization should be regarded as a process of monitoring the arterial blood pressure within the limits of the cardiac cycle and changes of its form with the aim of improving the energy balance of the heart. The coordination of the pumping function and that of the cardio-vascular system comes to a problem of shaping the monitoring action that depends upon three variables, viz. the time lag tepsilon, actuation of the unit relative to the base cardiosignal, duration of the pumping phase tpi and the signal level at the pump's inlet U(t). A number of researchers consider tepsilon and tpi to be a function of the cardiac contractions period and determine them in different ways, employing for this purpose extrapolation, stochastic characteristics, etc. Of late, in addition to the period of cardiac contractions extremal, mean integral values of the systolic and diastolic pressure, the level of pressure at the instant of the cardiac valves closure and others have also come in use. There are shortcomings in the proposed cardiosynchronization algorhythms: their empiric nature and also the fact that the monitoring action includes merely variables tepsilon and tpi and does not carry function U(t), which reflects the intensity of the pump's operation.