Clinical work sampling A new approach to the problem of in-training evaluation.

OBJECTIVE: Existing systems of in-training evaluation (ITE) have been criticized as being unreliable and invalid methods for assessing student performance during clinical education. The purpose of this study was to assess the feasibility, reliability, and validity of a clinical work sampling (CWS) approach to ITE. This approach focused on the following: (1) basing performance data on observed behaviors, (2) using multiple observers and occasions, (3) recording data at the time of performance, and (4) allowing for a feasible system to receive feedback. PARTICIPANTS: Sixty-two third-year University of Ottawa students were assessed during their 8-week internal medicine inpatient experience. MEASUREMENTS AND MAIN RESULTS: Four performance rating forms (Admission Rating Form, Ward Rating Form, Multidisciplinary Team Rating Form, and Patient's Rating Form) were introduced to document student performance. Voluntary participation rates were variable (12%-64%) with patients excluded from the analysis because of low response rate (12%). The mean number of evaluations per student per rotation (19) exceeded the number of evaluations needed to achieve sufficient reliability. Reliability coefficients were high for the Ward Form (.86) and the Admission Form (.73) but not for the Multidisciplinary Team (.22) Form. There was an examiner effect (rater leniency), but this was small relative to real differences between students. Correlations between the Ward Form and the Admission Form were high (.47), while those with the Multidisciplinary Team Form were lower (.37 and .26, respectively). The CWS approach ITE was considered to be content valid by expert judges. CONCLUSIONS: The collection of ongoing performance data was reasonably feasible, reliable, and valid.

Educating future physicians for Ontario: phase II.

In 1990, a collaborative project was launched to determine what the people of Ontario expect of their physicians and how the programs that prepare future physicians should be changed in response. The project, called Educating Future Physicians for Ontario (EFPO), brought together the five Ontario medical schools, the Council of Ontario Faculties of Medicine (COFM); a nonprofit, charitable organization, Associated Medical Services (AMS); and the Ontario Ministry of Health. The first phase ran for five years and was described in the November 1998 issue of Academic Medicine. After an external review, the project was continued for a second phase (EFPO II) for four more years until December 1998; that second phase is the topic of this article. EFPO II (1) focused more on residents' education; (2) emphasized four of the EFPO I-created physician roles in project activities; (3) maintained the province-wide, inter-institutional medical education framework of phase I, but fostered greater involvement of the seven sites (five medical schools and two regional health centers) in project activities; (4) stressed five project components (e.g., needs assessment and community partnerships) and worked for collaboration among components at all sites; (5) enhanced the original EFPO I Fellowship Program by adding residents and community fellows to the existing fellowships and by initiating leadership development activities, all of which bode well for the future leadership of medical education in Ontario. Students and residents played a vital role in EPFO II. Most of EFPO II's objectives were met, but the overall view of external reviewers was that the project was less successful than EFPO I. For example, the impact on clinical education, especially residency education, was less than anticipated. On the other hand, the project helped encourage the wide adoption of the eight physician roles that originated in EFPO I and advanced faculty development and assessment activities based on these roles. A third phase of EFPO concerning continuing medical education was planned, but support was not available. However, one of the funders will continue to support the successful fellowship and leadership program and the provincial education network for the next three years. Overall, the two phases of EFPO substantially modified medical education in Ontario to make it more responsive to evolving social needs.

Incidence and natural history of left ventricular thrombus following anterior wall acute myocardial infarction.

Previous studies have reported left ventricular (LV) thrombus in 20% to 56% of patients after anterior wall acute myocardial infarction (AMI). The Healing and Early Afterload Reducing Therapy (HEART) study was a prospective study comparing effects of early (24 hours) or delayed (14 days) initiation of ramipril, an angiotensin-converting enzyme inhibitor, on LV function after anterior wall AMI. This ancillary study assessed prevalence of LV thrombus. Two-dimensional echocardiography was performed on days 1, 14, and 90 after myocardial infarction. The cohort consisted of 309 patients. Q-wave anterior wall AMI occurred in 78%; 87% received reperfusion therapy. The prevalence of LV thrombus was 2 of 309 (0.6%) at day 1, 11 of 295 (3.7%) at day 14, and 7 of 283 (2.5%) at day 90. One patient had thrombus at 2 examinations. The day 1 echocardiogram was not correlated with thrombus development. LV size increased more in patients with thrombus than in those without thrombus. Patients with thrombus had more wall motion abnormality after day 1 than patients without thrombus (p = 0.03). Thus, the current prevalence of LV thrombus in anterior wall AMI is lower than previously reported, possibly due to changes in AMI management. Preservation of LV function is likely to be an important mechanism. Most thrombi are seen by 2 weeks after AMI. Resolution documented by echocardiography is frequent.

Depressive disorders in relatives of anorexia nervosa patients with and without a current episode of nonbipolar major depression.

The first-degree relatives of anorexia nervosa patients with current nonbipolar major depression had a higher rate of depression than the relatives of anorexic patients without current depression, whose rate was similar to that for relatives of normal control subjects.

Squash ball to eye ball: the likelihood of squash players incurring an eye injury.

The records of the 118 patients treated as Southampton Eye Hospital during 1978-9 for injuries incurred while playing squash, badminton, tennis, table tennis, cricket, and football show that for squash the main cause of eye injury was the player being hit by the ball. Severe eye injuries--those requiring treatment as an inpatient--were rare but much more frequent than such injuries in other sports. Less serious injuries--those requiring treatment as an outpatient--were also rare, with a frequency comparable with that of similar injuries in football and badminton. Squash players are most unlikely to incur an eye injury, but should this occur it has far-reaching consequences both in the short and the long term. Each individual player must weigh these chances and consequences against the possible inconvenience of using some form of eye protection.