Challenges of implementing competency-based medical education postgraduate training programs: the issue of context / Desafíos de la implementación de programas de formación de posgrado en educación médica basada en competencias: la cuestión del contexto

Introduction: Competency-based medical education (CBME) is being adopted worldwide. The aim of this paper is to discuss the evolution of CBME and address some perceived challenges in CBME curriculum development and implementation in postgraduate (residency) medical education. Methods: This is an opinion paper based on lived experiences and personal beliefs. The authors have professional training in medical education and are actively involved in CBME research, curriculum development and implementation around the world. Results: The issue of local and system-wide context seems to be of particular importance to individuals, programs, institutions, governing bodies and other stakeholders involved in the development and implementation of CBME programs. CBME has evolved differently at different places, and there are concerns regarding the fidelity of implementation. Stakeholders have been dealing with challenging questions in their CBME journeys, which reflect the varied, complex and dynamic nature of health and education systems. Recently, scholars have established core components of any CBME program. Discussion and conclusions: CBME design should benefit from ground-up strategies that consider the local context. It is essential to approach implementation with a quality improvement lens and pay special attention to the fidelity and integrity of the core CBME components.

Introducción: la educación médica basada en competencias (CBME) se está adoptando en todo el mundo. El objetivo de este artículo es discutir la evolución de la CBME y abordar algunos desafíos percibidos en el desarrollo y la implementación de los estándares de CBME en la educación médica de posgrado (residencia). Métodos: este es un artículo de opinión basado en experiencias vividas y creencias personales. Los autores tienen formación profesional en educación médica y participan activamente en la investigación, el desarrollo y la implementación de programas de CBME en varios países. Resultados: la cuestión del contexto local y de todo el sistema parece ser de particular importancia para las personas, los programas, las instituciones, los órganos de gobierno y otras partes inte-resadas involucradas en el desarrollo y la implementación de los programas de CBME. La CBME ha evolucionado de manera diferente en diferentes lugares y existen preocupaciones con respecto a la fidelidad de la implementación. Las partes interesadas han estado lidiando con cuestiones difíciles en sus proyectos de CBME, que reflejan la naturaleza variada, compleja y dinámica de los sistemas de salud y educación. Recientemente, los académicos han establecido componentes centrales de cualquier programa CBME. Discusión y conclusiones: el diseño de la CBME debería beneficiarse de estrategias de base que consideren el contexto local. Sin embargo, es importante abordar la implementación con una lente de mejora de la calidad y prestar especial atención a la fidelidad e integridad de los componentes centrales de la CBME.

Impact of a 1-day urodynamic course on knowledge, perceptions, and attitudes of urology residents.

AIMS: No evidence-informed educational curriculum is available for designing urodynamics (UDS) courses. We evaluated the learning outcomes of a short-lasting urodynamic course for urology residents. METHODS: Urology residents of postgraduate years 4 and 5 (n = 13 and n = 1316, respectively) attended a 1-day urodynamic course. Learning objectives included patient preparation, indication and technique, terminology, trace interpretation, and impact on patient management. Instructional methods consisted of short lectures (3 h) and case-based discussions (7.5 h). Learners' reactions, modifications of perceptions and attitudes, and acquisition of knowledge and skills were assessed by three written tests with a single group, pretest, posttest 1, and posttest 2 design. Tests were conducted precourse, 1 week after, and 4 months after the course. RESULTS: All participants felt more confident in several urodynamic competencies after the course, including patient preparation, urodynamic indication and technique, terminology, trace interpretation, and impact for patient management. These perceptions remained unchanged after 4 months. Most became stricter in the indication of UDS, including 20 (87.0%) at posttest 1 and 8 (66.7%) at posttest 2. The mean number of correct answers in the knowledge evaluation was 52.2% versus 61.4% versus 56.7%, respectively at pretest, posttest 1, and posttest 2; p = 0.535). All participants rated the course as very useful or useful in both posttest evaluations. CONCLUSIONS: Our study demonstrates that a 1-day urodynamic course can promote lasting improvements in self-reported perceptions, attitudes, and urodynamic-related competencies of urology residents. Further studies using evidence-informed educational principles are needed to determine the effect of specific educational interventions on urodynamic competencies in different contexts.

Comparison between clinical diagnoses and autopsy findings in a pediatric intensive care unit in São Paulo, Brazil.

OBJECTIVE: To verify the frequency of discrepancies between clinical diagnoses and autopsy findings in patients from a pediatric intensive care unit and to look for predictive factors of the discrepancies. DESIGN: Prospective evaluation performed between September 1996 and December 1998. SETTING: Eight-bed pediatric intensive care unit of a university hospital. PATIENTS: One hundred and two autopsies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Disagreements between autopsy and antemortem diagnoses were classified as proposed by Goldman. Patient age, presence of underlying disease, and length of stay were studied as possible predictive factors for diagnosis discrepancies. During the 28 months of study there were 779 admissions to the pediatric intensive care unit; the death rate was 26% and the autopsy rate was 55%. One hundred and two of 114 (89.5%) autopsies were evaluated. The median age of the patients was 21 months, and 85% of them had a previous underlying disease. One third of patients died before 24 hrs of admission to the pediatric intensive care unit. The autopsy revealed unexpected findings in 73 study patients (72%), 33 of which were related to "major diagnoses" (Goldman's classes I or II), either causes of death or main underlying disease. In 12 patients (12%), the correct diagnosis, if known before death, might have led to a change in the patient's therapy or outcome (class I). Unexpected findings in this group included viral or fungal infection and pulmonary embolism. None of the possible predictive factors that we studied showed significant statistical association between clinical and autopsy discrepant diagnoses in the univariate analysis. CONCLUSIONS: Although diagnoses of both cause of death and underlying disease were accurate in most cases before death, some autopsies revealed findings that would have changed intensive care unit therapy. Nonbacterial infections and pulmonary thromboembolism should always be considered when managing critically ill patients with underlying disease. Autopsy examinations continue to provide important information, especially in the pediatric intensive care unit setting, despite the advances in diagnostic technology.