Asking for Less and Getting More: The Impact of Broadening a Rater's Focus in Formative Assessment.

PURPOSE: There may be unintended consequences of broadening the competencies across which health professions trainees are assessed. This study was conducted to determine whether such broadening influences the formative guidance assessors provide to trainees and to test whether sequential collection of competency-specific assessment can overcome setbacks of simultaneous collection. METHOD: A randomized between-subjects experimental design, conducted in Toronto and Halifax, Canada, in 2016-2017 with paramedic educators experienced in observing/rating, in which observers' focus was manipulated. In the simultaneous condition, participants rated four unscripted (i.e., spontaneously generated) clinical performances using a six-dimension global rating scale and provided feedback. In three sequential conditions, participants were asked to rate the same performances and provide feedback but for only two of the six dimensions. Participants from these conditions were randomly merged to create a "full score" and set of feedback statements for each candidate. RESULTS: Eighty-seven raters completed the study; 23 in the simultaneous condition and 21 or 22 for each pair of dimensions in the sequential conditions. After randomly merging participants, there were 21 "full scores" in the sequential condition. Compared with the sequential condition, participants in the simultaneous condition demonstrated reductions in the amount of unique feedback provided, increased likelihood of ignoring some dimensions of performance, lessened variety of feedback, and reduced reliability. CONCLUSIONS: Sequential or distributed assessment strategies in which raters are asked to focus on less may provide more effective assessment by overcoming the unintended consequences of asking raters to spread their attention thinly over many dimensions of competence.

Pregnancy outcomes following maternal exposure to second-generation antipsychotics given with other psychotropic drugs: a cohort study.

OBJECTIVES: Second-generation antipsychotics (SGAs), in conjunction with other psychotropic medications, are increasingly used to treat psychiatric disorders in pregnancy. The few available studies investigating the reproductive safety of SGAs did not reach conclusive results, and none have compared monotherapy with polytherapy involving other psychotropic medications. DESIGN: Descriptive cohort study using a prospectively collected database. SETTING: Motherisk Program, The Hospital for Sick Children, Toronto, Canada. PARTICIPANTS: 133 women exposed to SGAs and other psychotropic drugs and 133 matched healthy controls were assessed and analysed. Outcomes of mother-child pairs exposed to SGAs in monotherapy (N=37) were compared with those exposed to SGAs with other psychotropic medications (in polytherapy; N=96). MAIN OUTCOME MEASURES: Maternal, pregnancy, delivery and neonatal outcomes. RESULTS: 72% of exposed women received SGAs in polytherapy, and 101 women took their medications throughout pregnancy. These women had significantly higher pre-pregnancy weight, experienced more associated comorbidities and instrumental deliveries, and delivered a greater proportion of large for gestational age neonates. There were no differences in maternal weight gain in pregnancy between the exposed and comparison groups and between the monotherapy-exposed and polytherapy-exposed subgroups. The exposed neonates were more likely to be born premature, were admitted more often to the neonatal intensive care unit, presented with poor neonatal adaptation signs and had higher rates of congenital malformations. All the aforementioned neonatal outcomes were found mainly in the polytherapy subgroup. CONCLUSIONS: The use of SGAs in polytherapy was prevalent in the assessed cohort and was associated with adverse pregnancy outcomes for both the mother and the child. In utero exposure to SGA monotherapy appears to be associated with less risk to the fetus. Future research should focus on polytherapy in pregnancy in order to define its reproductive safety and to separate the effects of medication exposure, underlying psychopathology and associated comorbidities.