What are the features of targeted or system-wide initiatives that affect diversity in health professions trainees? A BEME systematic review: BEME Guide No. 50.

BACKGROUND/PURPOSE: There is interest to increase diversity among health professions trainees. This study aims to determine the features/effects of interventions to promote recruitment/admission of under-represented minority (URM) students to health professions programs. METHODOLOGY: This registered BEME review applied systematic methods to: title/full-text inclusion review, data extraction, and quality assessment (QA). Included studies reported outcomes for interventions designed to increase diversity of health professions education (HPE) programs' recruitment and admissions. RESULTS: Of 7225 studies identified 86 met inclusion criteria. Interventions addressed: admissions (34%), enrichment (19%), outreach (15%), curriculum (3%), and mixed (29%). They were mostly single center (76%), from the United States (81%), in medicine (45%) or dentistry (22%). URM definition was stated in only 24%. The dimension most commonly considered was ethnicity/race (88%). The majority of studies (81%) found positive effects. Heterogeneity precluded meta-analysis. Qualitative analysis identified key features: admissions studies points systems and altered weightings; enrichment studies highlighted academic, application and exam preparation, and workplace exposure. DISCUSSION/CONCLUSIONS: Several intervention types may increase diversity. Limited applicant pools were a rate-limiting feature, suggesting efforts earlier in the continuum are needed to broaden applicant pools. There is a need to examine underlying cultural and external pressures that limit programs' acceptance of initiatives to increase diversity.

The effectiveness of team-based learning on learning outcomes in health professions education: BEME Guide No. 30.

BACKGROUND: Team-Based Learning (TBL) is a student-centred active learning method, requiring less faculty time than other active learning methods. While TBL may have pedagogical value, individual studies present inconsistent findings. The aim of this systematic review was to assess the effectiveness of TBL on improving learning outcomes in health professions education. METHODS: A peer-reviewed systematic review protocol was registered with the Best Evidence in Medical Education (BEME) organization. After comprehensive literature searching, title and full-text review were completed by two independent reviewers. Included studies assessed TBL and a valid comparator in health professions. Included studies were assessed for methodological quality by two independent reviewers. Studies were categorised by outcomes using the Kirkpatrick framework. RESULTS: Of 330 screened titles, 14 were included. Seven studies reported significant increase in knowledge scores for the TBL group, four reported no difference and three showed improvement but did not comment on statistical significance. Only one study reported significant improvement in learner reaction for the TBL group while another study reported a significant difference favouring the comparator. CONCLUSIONS: Despite improvement in knowledge scores, there was mixed learner reaction. This may reflect the increased demands on learners in this student-centred teaching strategy, although further study is needed.

The effects of audience response systems on learning outcomes in health professions education. A BEME systematic review: BEME Guide No. 21.

BACKGROUND: Audience response systems (ARS) represent one approach to make classroom learning more active. Although ARS may have pedagogical value, their impact is still unclear. This systematic review aims to examine the effect of ARS on learning outcomes in health professions education. METHODS: After a comprehensive literature search, two reviewers completed title screening, full-text review and quality assessment of comparative studies in health professions education. Qualitative synthesis and meta-analysis of immediate and longer term knowledge scores were conducted. RESULTS: Twenty-one of 1013 titles were included. Most studies evaluated ARS in lectures (20 studies) and in undergraduates (14 studies). Fourteen studies reported statistically significant improvement in knowledge scores with ARS. Meta-analysis showed greater differences with non-randomised study design. Qualitative synthesis showed greater differences with non-interactive teaching comparators and in postgraduates. Six of 21 studies reported student reaction; 5 favoured ARS while 1 had mixed results. CONCLUSION: This review provides some evidence to suggest the effectiveness of ARS in improving learning outcomes. These findings are more striking when ARS teaching is compared to non-interactive sessions and when non-randomised study designs are used. This review highlights the importance of having high quality studies with balanced comparators available to those making curricular decisions.

Teaching musculoskeletal clinical skills to medical trainees and physicians: a Best Evidence in Medical Education systematic review of strategies and their effectiveness: BEME Guide No. 18.

BACKGROUND: Musculoskeletal (MSK) complaints make up 12-20% of primary health visits and are a source of significant expenditures and morbidity. Despite this, MSK examination is an area of weakness among practising physicians. Several studies have highlighted the need for increased MSK physical exam teaching. However, increased teaching time alone does not guarantee improvement in these skills. Thus, we aimed to identify interventions that are effective in promoting transfer of MSK clinical skills. METHODS: The review protocol was approved by the Best Evidence in Medical Education (BEME) organization. A comprehensive search was conducted and systematic review methods were applied. Data were not pooled statistically due to heterogeneity. RESULTS: About 5089 titles were screened; 24 studies were included. Eighteen of 24 studies focused on undergraduate medical education. Five of nine studies favoured patient educator. Five of six studies favoured interactive small groups, two of four studies favoured computer-assisted learning, and two of two studies favoured peer learning. Individual studies demonstrated effectiveness of reminder sheets and Gait Arms Legs Spine teaching, respectively. CONCLUSIONS: This study supports the use of different instructional methods that engage learners and provide meaningful learning contexts. The majority of the studies support patient educators and interactive small group teaching.

The impact of trained patient educators on musculoskeletal clinical skills attainment in pre-clerkship medical students.

BACKGROUND: Despite the high burden of musculoskeletal (MSK) diseases, few generalists are comfortable teaching MSK physical examination (PE) skills. Patient Partners® in Arthritis (PP®IA) is a standardized patient educator program that could potentially supplement current MSK PE teaching. This study aims to determine if differences exist in MSK PE skills between non-MSK specialist physician and PP®IA taught students. METHODS: Pre-clerkship medical students attended 2-hour small group MSK PE teaching by either non-MSK specialist physician tutors or by PP®IA. All students underwent an MSK OSCE and completed retrospective pre-post questionnaires regarding comfort with MSK PE and interest in MSK. RESULTS: 83 students completed the OSCE (42 PP®IA, 41 physician taught) and 82 completed the questionnaire (42 PP®IA, 40 physician taught). There were no significant differences between groups in OSCE scores. For all questionnaire items, post-session ratings were significantly higher than pre-session ratings for both groups. In exploratory analysis PP®IA students showed significantly greater improvement in 12 of 22 questions including three of five patient-centred learning questions. CONCLUSIONS: PP®IA MSK PE teaching is as good as non-MSK specialist physician tutor teaching when measured by a five station OSCE and provide an excellent complementary resource to address current deficits in MSK PE teaching.

Musculoskeletal examination teaching by patients versus physicians: how are they different? Neither better nor worse, but complementary.

BACKGROUND: Musculoskeletal (MSK) complaints comprise 12-20% of primary healthcare; however, practicing physicians' MSK physical examination (PE) skills are weak. Further, there is a shortage of specialists able to effectively teach this subject. Previous evaluations of patient educators have yielded mixed results. AIMS: The aim of this study is to document how teaching by patient educators and physician tutors in MSK PE skills differs. METHODS: A qualitative researcher observed, video-recorded, and took notes during preclerkship MSK PE teaching sessions given by patient educators or physician tutors. The researcher identified themes which were evaluated by collective case study methods. RESULTS: Two patient educator and four physician groups were evaluated. The patient educators were more consistent regarding content and style than the physicians. There appeared to be a continuum in teaching organization from patient educator to novice physician tutors to experienced physician tutors. The patient educators consistently covered all major joints (physicians did not); physicians were more likely to request verbalization of actions, relate findings to history, receive questions, and use opportunistic teaching moments. CONCLUSIONS: Understanding preclerkship MSK teaching by patient educators compared to physician tutors is necessary for appropriate targeting of the existing Patient Partners® in Arthritis patient educator program and to guide the development of future MSK teaching initiatives.

How confident are internal medicine residents in rheumatology versus other common internal medicine clinical skills: an issue of training time or exposure?

The objective of this study was to determine self-confidence of internal medicine (IM) residents regarding rheumatology clinical skills and factors that may affect their confidence. Permission was sought to e-mail a web-based survey to IM residents at all 13 English language Canadian internal medicine programs. Residents were asked to rank self-confidence in rheumatology, cardiology, respirology, and gastroenterology skills. Further questions included site and year of training, career interests, rheumatology experiences, learning opportunities, and assessment frequency. These factors were analyzed by univariate and multivariate analyses. Two hundred sixteen residents (21.8%) from all 13 sites responded to the survey. Resident self-confidence in rheumatology diagnoses was 5.24/10, lower than all three comparator subspecialties. Increasing teaching exposure had a more significant impact on confidence in rheumatology than on comparator subspecialties. Increasing year of training had no association with higher self-confidence for rheumatology, in contrast to the increase in confidence seen with increased year of training for each comparator subspecialty. Further analysis demonstrated that the completion of a rheumatology rotation, increasing learning opportunities, annual assessment, and career interest were associated with greater resident self-confidence. Resident self-confidence for rheumatology skills is cautious at best and is lower than other common subspecialties. Self confidence improves with targeted rheumatology clinical experience and teaching, but does not improve solely with higher year of IM training. Furthermore, the impact of rheumatology teaching is greater than that of other common IM subspecialties. This information is critical to the planning and implementation of effective rheumatology curricula within internal medicine residency programs.

Exertional paraspinal muscle rhabdomyolysis and compartment syndrome: a cause of back pain not to be missed.

Exertional compartment syndrome has been described and implicated in pain syndromes involving several fascial compartments. This entity is classically characterized in the legs, feet and forearms of athletes. We describe a case of acute, severe exertional compartment syndrome of the paraspinal muscles in a young and healthy male ultimately resulting in significant rhabdomyolysis and acute kidney injury. The rarity of the syndrome has prevented the establishment of specific guidelines for management; therefore, we will discuss this case in the context of similar previously reported cases, contrasting the various treatment approaches and outcomes described in previous reports. This discussion outlines a syndrome not commonly considered in the differential diagnosis of back pain.

Pregnancy and rheumatic disease: "by the book" or "by the doc".

Pregnancy is an important condition that can affect and be affected by rheumatic disease. Overall, pregnancy is viewed as a Th2-predominant state, but several Th1-related cytokines are vital to early pregnancy. In rheumatoid arthritis for example, the majority of women improve by the beginning of the second trimester, but the majority (90%) will flare in the first 3 to 4 months postpartum. In contrast, systemic lupus erythematosus has an unpredictable course in pregnancy, leaving most rheumatologists to recommend a disease-quiescent state prior to conception. Other diseases such as scleroderma are less clear because the disease less commonly presents in the childbearing period. Many immunosuppressive medications for the rheumatic diseases are contraindicated in pregnancy because of their mechanisms of action leaving only a select few "safe" medications. Significant heterogeneity between the Food and Drug Administration (FDA) category for a medication and what a rheumatologist does in clinic leads to confusion on how a patient should be treated for active rheumatic disease both peripartum and postpartum, particularly if the patient is breastfeeding. We review the general state of pregnancy and how it is affected by prototypical rheumatic diseases including rheumatoid arthritis and systemic lupus erythematosus. In addition, we present the most commonly used disease-modifying antirheumatic drugs and immunosuppressants and explain the difference between the FDA category and clinical practice among rheumatologists. Finally, we provide some general recommendations on how to manage a rheumatic disease during pregnancy including: (a) preconception planning to ensure no teratogenic medications on board, (b) early disclosure of pregnancy to all caregivers including the rheumatologist, family physician, obstetrician, and maternal-fetal medicine specialist, and (c) planning of safe medication use for acute flare-ups and disease suppression peripartum and postpartum.

The current state of musculoskeletal clinical skills teaching for preclerkship medical students.

OBJECTIVE: Musculoskeletal (MSK) complaints have high prevalence in primary care practice (12%-20% of visits), yet many trainees and physicians identify themselves as weak in MSK physical examination (PE) skills. As recruitment to MSK specialties lags behind retirement rates, there is a shortage of physicians able to effectively teach this subject. We investigated current practices of Canadian undergraduate medical programs regarding the nature, amount, and source of preclerkship MSK PE clinical skills teaching; and documented the frequency and extent that Patient Partners in Arthritis (PPIA) are used in this educational setting. METHODS: A 2-page self-administered electronic questionnaire combining open- and close-ended questions was developed and piloted. It was distributed by e-mail to all Canadian undergraduate associate-deans and to 16/17 undergraduate MSK course organizers. RESULTS: Supervised practice in small groups and the PPIA are the most prevalent teaching methods. Objective structured clinical examinations are the most prevalent evaluation methods. The average number of hours devoted to teaching these skills is very small compared to the prevalence of MSK complaints in the population. Canadian schools' preclerkship MSK PE clinical skills teaching is heavily dependent on the contributions of non-MSK specialists. CONCLUSION: The weak link in the Canadian MSK PE educational cycle appears to be the amount of time available for students' deliberate practice with expert feedback. There is a need for methods to evaluate and further develop MSK PE teaching by non-MSK specialists. This and increased use of PPIA at the preclerkship level may provide students more time for practice with feedback.

Prevalence and associated factors for falls in women with established inflammatory polyarthritis.

OBJECTIVE: To determine the one-year period prevalence and factors associated with falls in a community based cohort of women with established inflammatory polyarthritis (IP). METHODS: The Norfolk Arthritis Register is a primary-care based inception cohort of subjects with IP aged 16 years and over. At the 10-year visit, subjects completed the Health Assessment Questionnaire (HAQ) and were examined for both active and inactive joint involvement. A subset of subjects was invited to complete a questionnaire about falls in the previous 12 months and questions about putative risk factors for falls. Logistic regression was used to determine whether there was any association between falls in the previous year and both putative disease and non-disease related risk factors. RESULTS: Of the 316 women (mean age 59 yrs) who completed the falls questionnaire, 34% reported a fall in the previous year. Falls were more frequent in those over age 75 years, although there was no significant linear increase in risk with age. Swollen joint count [per 10 joints, odds ratio (OR) 1.7; 95% confidence interval (CI) 1.0, 2.8] and increasing visual analog scale pain score (per 10 mm, OR 1.1; 95% CI 1.0, 1.2) were associated with an increased risk of falls. Those who fell had higher overall HAQ scores (OR 1.7; 95% CI 1.3, 2.3) as well as higher scores for all of the individual domains of the HAQ (OR 1.7 to 2.2). Similarly, low levels of outdoor physical activity (OR 3.3; 95% CI 1.7, 6.5), impaired vision (OR 2.7; 95% CI 1.2, 6.3), and impaired general health (OR 2.9; 95% CI 1.7, 4.8) were associated with an increased risk of falls. In a multivariate model, HAQ score, low levels of physical activity, impaired vision, and impaired general health were independently linked with falls. Sixty-one percent of subjects with 3 of these risk factors had reported a fall in the previous year. CONCLUSION: In this inception cohort of women with longstanding IP, one in 3 reported falling in the previous year. Using a simple measure, a group that had particularly high risk can be identified.