Systematic review of coaching to enhance surgeons' operative performance.

BACKGROUND: There is increasing attention on the coaching of surgeons and trainees to improve performance but no comprehensive review on this topic. The purpose of this review is to summarize the quantity and the quality of studies involving surgical coaching methods and their effectiveness. METHODS: We performed a systematic literature search through PubMed and PsychINFO by using predefined inclusion criteria. Evidence for main outcome categories was evaluated with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system and the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: Of a total 3,063 articles, 23 met our inclusion criteria; 4 randomized controlled trials and 19 observational studies. We categorized the articles into 4 groups on the basis of the outcome studied: perception, attitude and opinion; technical skills; nontechnical skills; and performance measures. Overall strength of evidence for each outcome groups was as follows: Perception, attitude, and opinion (Grading of Recommendations Assessment, Development, and Evaluation: Very Low, Medical Education Research Study Quality Instrument [MERSQI]: 10); technical skills (randomized controlled trials: High, 13.1; Observation studies: Very Low, 11.5); nontechnical skills (Very Low, 12.4) and performance measures (Very Low, 13.6). Simulation was the most used setting for coaching; more than half of the studies deployed an experienced surgeon as a coach and showed that coaching was effective. CONCLUSION: Surgical coaching interventions have a positive impact on learners' perception and attitudes, their technical and nontechnical skills, and performance measures. Evidence of impact on patient outcomes was limited, and the quality of research studies was variable. Despite this, our systematic review of different coaching interventions will benefit future coaching strategies and implementation to enhance operative performance.

Pediatric response to court-mandated Medicaid behavioral screening in Massachusetts.

OBJECTIVE: In 2007 in Massachusetts, a settlement of a class-action lawsuit on behalf of Medicaid beneficiaries mandated that primary care practices perform developmental, behavioral, and mental health screening using formal tools. The aim of this study was to assess perspectives from providers and practice staff about implementing developmental and mental health screening in response to the judicial ruling. METHODS: In this qualitative study, semistructured interviews were conducted with 18 physicians and staff from 11 pediatric and medicine-pediatric primary care practices in Eastern Massachusetts between April 2009 and November 2010. Using an interview guide, data on barriers and facilitators to implementing developmental and mental health screening, how practices selected tools, and what processes or changes made screening routine were collected. Clinicians were asked how screening changed the quality and/or content of well-child care visits. Interviews were transcribed and coded. Overarching themes were generated using thematic analysis. RESULTS: Participants were motivated to comply with the mandate, and most practices reported implementing routine screening for developmental and mental health problems over several months. Although certain aspects of screening were endorsed, many perceived that screening added little to quality of care, primarily because tools lacked sensitivity and specialty resources were too scarce to address concerns adequately. Practices' receptivity to change and physicians' sense of duty to comply facilitated implementation. No practice developed processes specifically to track and follow-up abnormal results. CONCLUSIONS: Implementation of mandated developmental and mental health screening could be facilitated by providing assistance with practice change, improving the quality of screening tools, and assuring adequate referral resources.

Riboswitches that sense S-adenosylhomocysteine and activate genes involved in coenzyme recycling.

We have identified a highly conserved RNA motif that occurs upstream of genes involved in S-adenosyl-L-methionine (SAM) recycling in many Gram-positive and Gram-negative species of bacteria. The phylogenetic distribution and the conserved structural features of representatives of this motif are indicative of riboswitch function. Riboswitches are widespread metabolite-sensing gene control elements that are typically found in the 5' untranslated regions (UTRs) of bacterial mRNAs. We experimentally verified that examples of this RNA motif specifically recognize S-adenosylhomocysteine (SAH) in protein-free in vitro assays, and confirmed that these RNAs strongly discriminate against SAM and other closely related analogs. A representative SAH motif was found to activate expression of a downstream gene in vivo when the metabolite is bound. These observations confirm that SAH motif RNAs are distinct ligand-binding aptamers for a riboswitch class that selectively binds SAH and controls genes essential for recycling expended SAM coenzymes.