Assessing the quality of feedback to general internal medicine residents in a competency-based environment.

CONSTRUCT: Competency Based Medical Education (CBME) is designed to use workplace-based assessment (WBA) tools to provide observed assessment and feedback on resident competence. Moreover, WBAs are expected to provide evidence beyond that of more traditional mid- or end-of-rotation assessments [e.g., In Training Evaluation Reports (ITERs)]. In this study, we investigated the quality of feedback in General Internal Medicine (GIM), by comparing WBA and ITER assessment tools. BACKGROUND: WBAs are hypothesized to improve written and numerical feedback to support the development and documentation of competence. In this study, we investigated residents' and preceptors' perceptions of WBA validity, usability, and reliability and the extent to which WBAs differentiate residents' performance when compared to ITERs. APPROACH: We used a mixed methods approach over a three-year period, including perspectives gathered from focus groups, interviews, along with numerical and narrative comparisons between WBA and ITERs in one GIM program. RESULTS: Our quantitative analysis of feedback from seven residents' clinical assessments showed that overall rates of actionable feedback, for both ITERs and WBAs, were low (26%), with only 9% of the total providing an improvement strategy. The provision of quality feedback was not significantly different between tools; although WBAs provided more actionable feedback, ITERs provided more strategies. We found that residents and preceptors indicated the narrative component of feedback was more constructive and effective than numerical scores. Both groups perceived the focus on specific workplace-based feedback was more effective than ITERs. CONCLUSIONS: Participants in this study viewed narrative, actionable, and specific feedback as essential, and an overall preference was found for written feedback over numerical assessments. However, our quantitative analyses showed that specific actionable feedback was rarely documented, despite finding an emphasis from both residents and preceptors of its importance for developing competency. Neither formative WBAs nor summative ITERs clearly provided better feedback, and both may still have a role in overall resident evaluation. Participant views differed in roles and responsibilities, with residents stating that preceptors should be responsible for initiating assessments and vice-versa. These results reveal an incongruence between resident and preceptor perceptions and practice around giving feedback and emphasize opportunities for programs adopting and implementing CBME to address how best to support residents and frontline clinical teachers.

ÉLABORATION: La formation médicale par compétences (CBME) est conçue pour utiliser les outils d'évaluation en milieu de travail (WBA) afin de fournir une évaluation formative et une rétroaction basés sur l'observationde la compétence des résidents. De plus, les WBA doivent fournir une preuve plus exacte que les évaluations traditionnelles à mi-cycle et en fin de cycle [p. ex. rapports d'évaluation en cours de formation (ITER)]. Dans cette étude, nous avons examiné la qualité de la rétroaction en médecine interne générale (GIM) en comparant les outils d'évaluation WBA et ITER. CONTEXTE: Les WBA sont pressentis pour être associés à une meilleure rétroaction narrative ou sur échelle quantitative pour appuyer le développement et la documentation de la compétence. Dans cette étude, nous avons examiné les perceptions des résidents et des superviseurs quant à la validité, l'utilité et la fiabilité de la WBA, et la façon dont les WBA différencient les performances des résidents par rapport aux ITER. APPROCHE: Nous avons utilisé une approche de méthodes mixtes sur une période de trois ans, notamment des perspectives recueillies auprès de groupes de discussion, des entrevues, et également des comparaisons numériques et narratives entre les WBA et les ITER liés à un programme de médecine interne générale. RÉSULTATS: Notre analyse quantitative de rétroaction basée sur sept évaluations cliniques de résidents démontre que les taux globaux de rétroaction pertinente, pour les ITER et les WBA, étaient bas (26 %), et que seulement 9 % de ces deux types d'évaluation suggéraient une stratégie d'amélioration. La qualité de la rétroaction n'était pas très différente entre les outils; les WBA ont fourni plus de rétroaction pertinente, mais les ITER ont fourni plus de stratégies. Selon nos observations, les résidents et les superviseurs ont indiqué que la partie narrative de la rétroaction était plus constructive et efficace que les évaluations par échelles quantitative. Les deux groupes ont estimé que l'accent mis sur la rétroaction en milieu de travail était plus efficace que les ITER. CONCLUSIONS: Les participants à cette étude ont estimé que les rétroactions narratives, pertinentes et spécifiques sont essentielles, et nous avons observé une préférence générale pour la rétroaction narrative plutôt que pour l'évaluation avec échelle quantitative. Cependant, nos analyses quantitatives ont démontré que la rétroaction pertinente spécifique était rarement documentée, bien que les résidents et les superviseurs insistent sur son importance quant au développement des compétences. Ni les WBA formatives ni les ITER sommatifs n'ont clairement fourni de meilleures rétroactions et les deux pourraient toujours avoir un rôle dans l'évaluation globale des résidents. Les opinions des résidents divergent de celles des superviseurs quant aux rôles et les responsabilités : les résidents affirment que les précepteurs ont la responsabilité d'initier les évaluations, et vice versa. Ces résultats révèlent une discordance entre les perceptions et les pratiques des résidents et des superviseurs quant aux rétroactions à apporter. Ils mettent également l'accent sur les opportunités pouraux les programmes qui adoptent et implantent la formation médicale par compétences pour trouver la meilleure façon d'appuyer les résidents et les enseignants cliniques sur le terrain.

Scaffolding for assessment success: using gradual release of responsibility to support resident transition to competency-based medical education.

Implication Statement In competency-based medical education (CBME), assessment is learner-driven; learners may fail to progress if assessments are not completed. The General Internal Medicine (GIM) program at Queen's University uses an educational technique known as scaffolding in its assessment strategy. The program applies this technique to coordinate early assessments with specific scheduled learning experiences and gradually releases the responsibility for assessment initiation to residents. Although outcomes of this innovation are still under investigation, we feel it has been valuable in supporting resident assessment capture and timely progression through stages of training. Other residency training programs could easily implement this technique to support the transition to Competency by Design.

Disturbances in blood flow and 'medicine's greatest imitator'.

First described in 1959, intravascular lymphoma (IVL) remains one of the most clinically challenging diagnoses due to its diverse and non-specific clinical manifestations and evasiveness in detection by standard investigations. Indeed, IVL deserves the title of 'medicine's greatest imitator'. We highlight a case of IVL where the diagnosis came too late in the clinical course, detected by random skin biopsy. Clinicians should strongly consider this diagnosis in presentations with persistent symptomatology despite appropriate interventions.

Subunit connectivity, assembly determinants and architecture of the yeast exocyst complex.

The exocyst is a hetero-octameric complex that has been proposed to serve as the tethering complex for exocytosis, although it remains poorly understood at the molecular level. Here, we purified endogenous exocyst complexes from Saccharomyces cerevisiae and showed that they are stable and consist of all eight subunits with equal stoichiometry. Using a combination of biochemical and auxin induced-degradation experiments in yeast, we mapped the subunit connectivity, identified two stable four-subunit modules within the octamer and demonstrated that several known exocyst-binding partners are not necessary for exocyst assembly and stability. Furthermore, we visualized the structure of the yeast complex by using negative-stain electron microscopy; our results indicate that the exocyst exists predominantly as a stable, octameric complex with an elongated architecture that suggests that the subunits are contiguous helical bundles packed together into a bundle of long rods.

Structural dynamics as a contributor to error-prone replication by an RNA-dependent RNA polymerase.

RNA viruses encoding high- or low-fidelity RNA-dependent RNA polymerases (RdRp) are attenuated. The ability to predict residues of the RdRp required for faithful incorporation of nucleotides represents an essential step in any pipeline intended to exploit perturbed fidelity as the basis for rational design of vaccine candidates. We used x-ray crystallography, molecular dynamics simulations, NMR spectroscopy, and pre-steady-state kinetics to compare a mutator (H273R) RdRp from poliovirus to the wild-type (WT) enzyme. We show that the nucleotide-binding site toggles between the nucleotide binding-occluded and nucleotide binding-competent states. The conformational dynamics between these states were enhanced by binding to primed template RNA. For the WT, the occluded conformation was favored; for H273R, the competent conformation was favored. The resonance for Met-187 in our NMR spectra reported on the ability of the enzyme to check the correctness of the bound nucleotide. Kinetic experiments were consistent with the conformational dynamics contributing to the established pre-incorporation conformational change and fidelity checkpoint. For H273R, residues comprising the active site spent more time in the catalytically competent conformation and were more positively correlated than the WT. We propose that by linking the equilibrium between the binding-occluded and binding-competent conformations of the nucleotide-binding pocket and other active-site dynamics to the correctness of the bound nucleotide, faithful nucleotide incorporation is achieved. These studies underscore the need to apply multiple biophysical and biochemical approaches to the elucidation of the physical basis for polymerase fidelity.

Crystal structure of poliovirus 3CD protein: virally encoded protease and precursor to the RNA-dependent RNA polymerase.

Poliovirus 3CD is a multifunctional protein that serves as a precursor to the protease 3C(pro) and the viral polymerase 3D(pol) and also plays a role in the control of viral replication. Although 3CD is a fully functional protease, it lacks polymerase activity. We have solved the crystal structures of 3CD at a 3.4-A resolution and the G64S fidelity mutant of 3D(pol) at a 3.0-A resolution. In the 3CD structure, the 3C and 3D domains are joined by a poorly ordered polypeptide linker, possibly to facilitate its cleavage, in an arrangement that precludes intramolecular proteolysis. The polymerase active site is intact in both the 3CD and the 3D(pol) G64S structures, despite the disruption of a network proposed to position key residues in the active site. Therefore, changes in molecular flexibility may be responsible for the differences in fidelity and polymerase activities. Extensive packing contacts between symmetry-related 3CD molecules and the approach of the 3C domain's N terminus to the VPg binding site suggest how 3D(pol) makes biologically relevant interactions with the 3C, 3CD, and 3BCD proteins that control the uridylylation of VPg during the initiation of viral replication. Indeed, mutations designed to disrupt these interfaces have pronounced effects on the uridylylation reaction in vitro.

Natural history of elevated creatinine levels.

OBJECTIVE: To investigate what happens to the serum creatinine (SC) levels of people with initial mild elevations in SC; whether a stable, non-progressive elevation in SC level is the most common scenario; how common a progressive increase in SC is among primary care patients; and how often primary care patients with substantial elevations in SC (>300 micromol/L) progress to end-stage renal disease. DESIGN: Retrospective analysis of laboratory data and chart review. SETTING: Queen's University Family Medicine Centre in Kingston, Ont. PARTICIPANTS: All patients who had SC levels measured at a nearby hospital laboratory between January 1994 and December 1998. MAIN OUTCOME MEASURES: Recently recorded height and weight measurements, latest SC measurements (if available), whether patients had been referred to nephrologists, comorbidity, medications being taken, whether patients were currently undergoing dialysis or had received a renal transplant, and whether patients had died. RESULTS: In the 1434 charts of eligible patients, 64 (4.5%) had elevated initial SC levels (>130 micromol/L) recorded, and 57 of these contained follow-up SC levels also. Among these 57 patients, 32 (56%) saw their SC levels return to normal, including 50% of those whose initial levels had been >300 micromol/L. Only 7 patients (12%) with elevated SC levels progressed to higher levels during the follow-up period. Average age in the study group was 63 years; those with initial elevated SC levels were older than the average (70 years). CONCLUSION: More than half of those with initially elevated SC levels (>130 micromol/L) saw their levels return to normal, including patients whose initial levels had been >300 micromol/L. It seems that a single elevated SC measurement does not predict ongoing decline in renal function.