Programmatic Assessment in Emergency Medicine: Implementation of Best Practices.

BACKGROUND: Programmatic assessment is the intentional collection of key data from multiple sources for both assessment of learning and assessment for learning. OBJECTIVE: We developed a system of programmatic assessment (PA) to identify competency progression (summative) and assessment for learning to assist residents in their formative development. METHODS: The programmatic assessment was designed iteratively from 2014 through 2016. All assessments were first categorized by competency domain and source of assessment. The number of assessment modalities for each competency domain was collected. These multisource assessments were then mapped by program leadership to the milestones to develop a master PA blueprint. A resident learning management system provided the platform for aggregating formative and summative data, allowing residents and faculty ongoing access to guide learning and assessment. A key component of programmatic assessment was to support resident integration of assessment information through feedback by faculty after shifts and during monthly formal assessments, semiannual resident reviews, and summative judgments by the Clinical Competency Committee. RESULTS: Through the PA, the 6 competency domains are assessed through multiple modalities: patient care (22 different assessments), professionalism (18), systems-based practice (17), interprofessional and communication skills (16), medical knowledge (11), and practice-based learning and improvement (6). Each assessment provides feedback to the resident in various formats. Our programmatic assessment has been utilized for more than 2 years with iterative improvements. CONCLUSIONS: The implementation of programmatic assessment allowed our program to organize diverse, multisourced feedback to drive both formative and summative assessments.

Standard setting of script concordance tests using an adapted Nedelsky approach.

BACKGROUND: Standard setting in assessment seeks to apply meaning of achievement to an assessment score. Appropriate standard setting for script concordance tests (SCTs) remains a challenge, with existing methods representing norm-referenced approaches. AIMS: To develop a criterion-referenced standard setting approach for sct using an adapted nedelsky approach, to pilot feasibility, and to compare failure rates with two other methods. METHODS: Second- and third-year medical students were administered a 45-question SCT and results collated. Standard setting was applied using three approaches: (1) norm-referenced (student cohorts), (2) expert-referenced (student cohort compared to expert mean), and (3) adapted Nedelsky approach using answer key normalization. Feasibility and failure rates were measured. RESULTS: All standard setting approaches were feasible, with 60 additional minutes required for the Nedelsky standard setting exercise. Failure rates between the three approaches were similar (Year 2: 8.0-9.8% and Year 3: 2.1-7.6%), with the adapted Nedelsky approach representing an intermediate option (Year 2: 8.0% and Year 3: 3.5%). CONCLUSION: Standard setting SCT using the criterion-referenced method of an adapted Nedelsky approach was found to be both logically justifiable and logistically simple, and produced failure rates comparable to other currently utilized and less objective approaches.

Tomorrow's educators today? Implementing near-peer teaching for medical students.

BACKGROUND: The University of Adelaide offers a six-year undergraduate medical degree with a focus on small group learning. Senior medical students had previously received limited formal training in education skills, and were identified as an underutilised teaching resource. AIMS: To devise a programme in which senior students are exposed to the various facets of university teaching responsibilities and to evaluate its impact on both the tutors and the students. METHODS: A six week rotation in medical education for final year medical students was designed and implemented in 2010 to involve them in the development, delivery and assessment of the 1st and 2nd year medical programme as near-peer tutors (NPTs). RESULTS: Two years after the rotation's implementation, voluntary evaluation of both the junior students and NPTs was undertaken through a mixed methods approach of survey and focus group. Junior students (n=358) revealed the NPTs provided non-threatening learning environments, provided helpful feedback and acted as role models. Additionally, the NPTs (n=24) reported they had consolidated prior knowledge, developed their teaching skills and expressed a desire to be more involved in teaching in the future. CONCLUSIONS: The implementation of NPTs in the teaching of junior medical students appears to benefit both students and their near-peer colleagues. Involvement of NPTs in all facets of medical education through this rotation stands to not only foster potential interest in an academic pathway but also equip them with a variety of transferable skills which they can draw on as future educators in their profession.

Clinical reasoning - a guide to improving teaching and practice.

BACKGROUND: The process of clinical reasoning is undertaken by all clinicians, often automatically, and is the cognitive process that underlies diagnosis and management of a patient's presenting problem. The teaching of clinical reasoning can pose a challenge to the clinical teacher. OBJECTIVE: This article reviews the process of clinical reasoning and provides the teacher with a framework to teach clinical reasoning to students and junior doctors. DISCUSSION: By considering clinical reasoning as a skill to be learnt rather than a concept to be understood, a framework for teaching this skill can be developed. The learner initially observes a consultation by the teaching clinician, followed by the teacher explaining the reasoning processes used including hypothesising, hypothesis testing, re-analysis and differential diagnosis. The student then comments on the reasoning of the teacher in a subsequent consultation, followed by feedback from the teacher on the student's reasoning in a third consultation.

Vertical integration of teaching in Australian general practice--a survey of regional training providers.

OBJECTIVE: To examine vertical integration of teaching and clinical training in general practice and describe practical examples being undertaken by Australian general practice regional training providers (RTPs). DESIGN, SETTING AND PARTICIPANTS: A qualitative study of all RTPs in Australia, mid 2010. RESULTS: All 17 RTPs in Australia responded. Eleven had developed some vertical integration initiatives. Several encouraged registrars to teach junior doctors and medical students, others encouraged general practitioner supervisors to run multilevel educational sessions, a few coordinated placements, linkages and support across their region. Three RTPs provided case studies of vertical integration. CONCLUSIONS: Many RTPs in Australia use vertical integration of teaching in their training programs. RTPs with close associations with universities and rural clinical schools seem to be leading these initiatives.

Thromboembolic stroke: a rare complication associated with peri-procedural management of an epidural steroid injection.

BACKGROUND: Little attention has been afforded to the potential adverse sequelae of withholding anticoagulation therapy in a patient after neuraxial interventions. OBJECTIVE: Presenting a case of thromboembolic stroke in a patient after holding warfarin for a lumbar epidural steroid injection, previously unreported in published literature. The discussion that follows reviews the guidelines available to reduce the risk of thromboembolic events in anticoagulated patients in the periprocedural period. CASE REPORT: An 81-year-old female with radicular pain secondary to spinal stenosis had been seen on 5 previous occasions for lumbar epidural steroid injections. Prior to each procedure warfarin was held for 5-7 days with demonstrable reversal of anticoagulation to within the safe limits set for neuraxial techniques by the American Society of Regional Anesthesia and Pain Medicine. On the morning following the sixth injection the patient was admitted to the hospital for new onset slurred speech and left-sided hemiparesis. A computed tomography scan established an acute, localized infarct in the distribution of the right middle cerebral artery. Her symptoms were non-reversible and permanent. CONCLUSIONS: Thromboembolism is a potentially devastating complication associated with atrial fibrillation. Twenty percent of thromboembolic events in patients with atrial fibrillation are fatal, and greater than 50% result in permanent disability. While thromboembolic events following a brief period of normalization of coagulation for interventions appear rare, so is the incidence of epidural hematomas. Considering the high mortality and permanent rate of disability with thromboembolic events associated with atrial fibrillation, perhaps it is time to balance our focus on the complications of withholding anticoagulation with those of bleeding.

Trabecular rod buckling index in thoraco-lumbar vertebral bonedagger.

The need for improved mechanistic understanding of cancellous bone failure is at the core of important clinical problems such as osteoporosis, as well as basic biological issues such as bone formation and adaptation. Three-dimensional (3D) anaglyphs were produced from 15 T12 and L1 vertebral bodies, which encompass the adult life span in both sexes. The anaglyphs were viewed with red-green stereo glasses, using an image analyzer, and trabecular thickness and trabecular length were measured. From biomechanical principles, the strength of individual trabeculae can be estimated from measurement of trabecular rod thickness and trabecular rod length as the load to buckling index. The distribution of the load to buckling index was best described by a log normal curve. Trabecular rod thickness, trabecular rod length, and load to buckling index for males were consistently greater than for females. With aging, trabecular rod thickness, and the load to buckling index decrease for males while trabecular rod length increases for females. In this study, the load to buckling index for thoraco-lumbar vertebral trabecular rods potentially quantifies a greater risk of vertebral fracture for females. Decreased trabecular rod thickness or increased trabecular rod length result in the strength of trabeculae shifting closer to a putative fracture threshold. The corollary being that there is a reduced safety margin for resistance to mechanical loads for the vertebral bodies. The 3D anaglyph technique for measuring trabecular dimensions provides an accurate and precise methodology by which these morphological studies can be undertaken.