Communication and Ethics in the Clinical Examination.

At the heart of every effective patient-physician interaction is a relationship that is built on trust. Cultivating sound communication skills coupled with the awareness and application of ethical principles is integral to this process. One of the foremost challenges in competent practice is negotiating situations that arise at the bedside when such issues as patient autonomy, differing world views, honesty, and cost stewardship come into conflict. It is essential for health care providers to consider how to detect and prioritize these issues as they advocate for high-quality and patient-centered care.

Found in transition: applying milestones to three unique discharge curricula.

Introduction. A safe and effective transition from hospital to post-acute care is a complex and important physician competency. Milestones and Entrustable Professional Activities (EPA) form the new educational rubric in Graduate Medical Education Training. "A safe and effective discharge from the hospital" is an EPA ripe for educational innovation. Methods. The authors collaborated in a qualitative process called mapping to define 22 of 142 Internal Medicine (IM) curricular milestones related to the transition of care. Fifty-five participant units at an Association for Program Directors in Internal Medicine (APDIM) workshop prioritized the milestones, using a validated ranking process called Q-sort. We analyzed the Q-sort results, which rank the milestones in order of priority. We then applied this ranking to three innovative models of training IM residents in the transitions of care: Simulation (S), Discharge Clinic Feedback (DCF) and TRACER (T). Results. We collected 55 Q-sort rankings from particpants at the APDIM workshop. We then identified which milestones are a focus of the three innovative models of training in the transition of care: Simulation = 5 of 22 milestones, Discharge Clinic Feedback = 9 of 22 milestones, and TRACER = 7 of 22 milestones. Milestones identified in each innovation related to one of the top 8 prioritized milestones 75% of the time; thus, more frequently than the milestones with lower priority. Two milestones are shared by all three curricula: Utilize patient-centered education and Ensure succinct written communication. Two other milestones are shared by two curricula: Manage and coordinate care transitions across multiple delivery systems and Customize care in the context of the patient's preferences. If you combine the three innovations, all of the top 8 milestones are included. Discussion. The milestones give us a context to share individual innovations and to compare and contrast using a standardized frame. We demonstrate that the three unique discharge curricula in aggregate capture all of the highest prioritized milestones for this discharge EPA.

Description of a developmental criterion-referenced assessment for promoting competence in internal medicine residents.

RATIONALE: End-of- rotation global evaluations can be subjective, produce inflated grades, lack interrater reliability, and offer information that lacks value. This article outlines the generation of a unique developmental criterion-referenced assessment that applies adult learning theory and the learner, manager, teacher model, and represents an innovative application to the American Board of Internal Medicine (ABIM) 9-point scale. INTERVENTION: We describe the process used by Southern Illinois University School of Medicine to develop rotation-specific, criterion-based evaluation anchors that evolved into an effective faculty development exercise. RESULTS: The intervention gave faculty a clearer understanding of the 6 Accreditation Council for Graduate Medical Education competencies, each rotation's educational goals, and how rotation design affects meaningful work-based assessment. We also describe easily attainable successes in evaluation design and pitfalls that other institutions may be able to avoid. Shifting the evaluation emphasis on the residents' development of competence has made the expectations of rotation faculty more transparent, has facilitated conversations between program director and residents, and has improved the specificity of the tool for feedback. Our findings showed the new approach reduced grade inflation compared with the ABIM end-of-rotation global evaluation form. DISCUSSION: We offer the new developmental criterion-referenced assessment as a unique application of the competences to the ABIM 9-point scale as a transferable model for improving the validity and reliability of resident evaluations across graduate medical education programs.

Development of the objective structured system-interaction examination.

STUDY OBJECTIVE: The purpose of this study was to develop an objective method of evaluating resident competency in systems-based practice. STUDY DESIGN: Faculty developed a 12-station examination, the Objective Structured System-Interaction Examination (OSSIE), patterned after the Objective Structured Clinical Examinations (OSCEs), to evaluate residents' ability to effectively work within the complex medical system of care. Scenarios consisted of multiple situations, such as patient hand-offs, consultations, complicated discharges, and family meetings, in which residents interacted with simulated professionals, simulated patients, and simulated family members to demonstrate the systems-based skills. Twelve second-year residents participated in the OSSIE. FINDINGS: Along with the standardized professionals, a faculty member provided the resident with immediate feedback and completed an evaluation form designed specifically to assess systems-based practice. Residents, faculty, and staff evaluated the OSSIE and felt it provided a rich learning experience and was a beneficial means of formative assessment. The residents' third-year learning experiences were adapted to meet their needs, and suggestions were offered for curriculum revision. DISCUSSION: The OSSIE is unique in that it uses standardized professionals, involves scenarios in a variety of settings, and incorporates current technology, including an electronic health record and a state-of-the-art simulation laboratory, into the examination. Challenges to implementation include faculty time, scheduling of residents, and availability of resources. CONCLUSION: By using the OSSIE, faculty are able to assess, provide constructive feedback, and tailor training opportunities to improve resident competence in systems-based practice. Reliability and validity of an instrument developed for use with the OSSIE are currently being determined.

Septic right superior ophthalmic vein thrombosis complicated by left sphenoid sinusitis.

We report a case of septic right superior ophthalmic vein thrombosis complicated by left sphenoid sinusitis with methicillin-sensitive Staphylococcus aureus (MSSA). Early recognition by clinical symptoms, and computed tonography (CT) and magnetic resolution image (MRI) of the head and sinus is needed for prompt surgical drainage of the sinus and appropriate antimicrobial therapy. The use of steroids and anticoagulation for this condition is still debated.