IMG candidates' demographic characteristics as predictors of CEHPEA CE1 results.

OBJECTIVE: To assess the extent to which demographic characteristics are related to international medical graduate (IMG) candidate performance on the Centre for the Evaluation of Health Professionals Educated Abroad General Comprehensive Clinical Examination 1 (CE1). DESIGN: Retrospective study. SETTING: Toronto, Ont. PARTICIPANTS: All IMG candidates who registered for and took the CE1 in 2007 (n = 430), 2008 (n = 480), and 2009 (n = 472) were included in this analysis. All candidates completed the Centre for the Evaluation of Health Professionals Educated Abroad CE1, a 12-station objective structured clinical examination. MAIN OUTCOME MEASURES: Mean (SD) examination scores for groups based on demographic variables (age, region of medical training, and Medical Council of Canada Qualifying Examination Part 1 [MCCQE1] score) were calculated. Analysis of variance was done using CE1 examination total scores as the dependent variables. RESULTS: Candidates from countries where both medical education and patient care are conducted in English and those from South America and Western Europe achieved the highest scores, while candidates from the Western Pacific region and Africa achieved the lowest scores. Younger candidates achieved higher scores than older candidates. These results were consistent across the 3 years of CE1 examination administration. There was a significant relationship between MCCQE1 and CE1 scores in 2 of the 3 years: 2007 (r = 0.218, P < .001) and 2008 (r = 0.23, P < .01). CONCLUSION: The CE1 includes an assessment of communication skills; hence it is reasonable that candidates with stronger English skills have the highest scores on the CE1. Age, as a proxy for time since graduation, also has a substantial effect on examination scores, possibly owing to those further from their training lacking some currency of knowledge or being in focused rather than general practices. It is reasonable that those who had higher scores on the written test (the MCCQE1) would also have higher scores on the clinical test (the CE1). Demographic characteristics appear to be related to performance on the CE1.

Validation of a large-scale clinical examination for international medical graduates.

OBJECTIVE: To evaluate a new examination process for international medical graduates (IMGs) to ensure that it is able to reliably assign candidates to 1 of 4 competency levels, and to determine if a global rating scale can accurately stratify examinees into 4 levels of learners: clerks, first-year residents, second-year residents, or practice ready. DESIGN: Validation study evaluating a 12-station objective structured clinical examination. SETTING: Ontario. PARTICIPANTS: A total of 846 IMGs, and an additional 63 randomly selected volunteers from 2 groups: third-year clinical clerks (n = 42) and first-year family medicine residents (n = 21). MAIN OUTCOME MEASURES: The accuracy of the stratification of the examinees into learner levels, the impact of the patient-encounter ratings and postencounter oral questions, and between-group differences in total score. RESULTS: Reliability of the patient-encounter scores, postencounter oral question scores, and the total between-group difference scores was 0.93, 0.88, and 0.76, respectively. Third-year clerks scored the lowest, followed by the IMGs. First-year residents scored highest for all 3 scores. Analysis of variance demonstrated significant between-group differences for all 3 scores (P < .05). Postencounter oral question scores differentiated among all 3 groups. CONCLUSION: Clinical examination scores were capable of differentiating among the 3 groups. As a group, the IMGs seemed to be less competent than the first-year family medicine residents and more competent than the third-year clerks. The scores generated by the postencounter oral questions were the most effective in differentiating between the 2 training levels and among the 3 groups of test takers.

Game-based versus traditional case-based learning: comparing effectiveness in stroke continuing medical education.

OBJECTIVE: To evaluate family physicians' enjoyment of and knowledge gained from game-based learning, compared with traditional case-based learning, in a continuing medical education (CME) event on stroke prevention and management. DESIGN: An equivalence trial to determine if game-based learning was as effective as case-based learning in terms of attained knowledge levels. Game questions and small group cases were developed. Participants were randomized to either a game-based or a case-based group and took part in the event. SETTING: Ontario provincial family medicine conference. PARTICIPANTS: Thirty-two family physicians and 3 senior family medicine residents attending the conference. INTERVENTION: Participation in either a game-based or a case-based CME learning group. MAIN OUTCOME MEASURES: Scores on 40-item immediate and 3-month posttests of knowledge and a satisfaction survey. RESULTS: Results from knowledge testing immediately after the event and 3 months later showed no significant difference in scoring between groups. Participants in the game-based group reported higher levels of satisfaction with the learning experience. CONCLUSION: Games provide a novel way of organizing CME events. They might provide more group interaction and discussion, as well as improve recruitment to CME events. They might also provide a forum for interdisciplinary CME. Using games in future CME events appears to be a promising approach to facilitate participant learning.

Bacteriology, inflammation, and healing: a study of nanocrystalline silver dressings in chronic venous leg ulcers.

BACKGROUND: Healing of venous leg ulcers (VLUs) is often stalled despite compression therapy. Increased bacterial burden and chronic inflammation are 2 factors that may prevent these chronic VLUs (CVLUs) from healing. There is evidence that nanocrystalline silver dressings may reduce bacterial levels, decrease the chronic inflammatory response, and thus promote wound healing. OBJECTIVE: To determine the effects of a nanocrystalline silver barrier dressing on wound microflora, wound inflammation, and healing in CVLUs. METHOD: Stalled VLUs in 15 patients were managed using nanocrystalline silver dressings under 4-layer compression bandages. Paired skin biopsies at baseline and at an average of study week 6.5 were analyzed for bacteria and inflammatory infiltrates. Serum silver levels were monitored, and wound healing was assessed using planimetry. RESULTS: VLUs in 4 patients healed, and 8 other patients completed the 12-week study. There was a significant reduction in the log10 total bacterial count between baseline and final biopsies (P = .011). Greater numbers of lymphocytes were associated with an increased reduction of ulcer size at week 6.5 and final assessment at week 12 (P < .05). Heavy neutrophilic infiltration in skin biopsies at week 6.5 was associated with high bacterial counts and delayed healing (P = .037). The median reduction in ulcer surface area for all patients was 83.5%. Serum silver levels increased slightly, but values were within the normal range. CONCLUSION: A nanocrystalline silver dressing combined with 4-layer bandaging was safe and successful in promoting healing in stalled CVLUs. Healing was associated with a reduction in wound bacteria and neutrophilic inflammation with an associated persistent or high lymphocyte count, as determined by wound biopsy.

Derrame pleural eosinofílico após trauma: relato de caso / Eosinophilic pleural effusion after trauma: a case report

RFC, mulher de 85 anos com desconforto em hemitórax direito. Atomografia de tórax na admissão demonstrou derrame pleural diretoe a videotoracoscopia identificou hematomas traumáticos semoutras lesões. O trauma é um diagnóstico diferencial de derramespleurais eosinofílicos. A videotoracoscopia tem sido preconizadacomo procedimento de escolha para diagnósticos diferenciais emderrames pleurais.

Creative professional activity: an additional platform for promotion of faculty.

Academic promotion has traditionally been based on research and teaching, but faculty members' contributions to the profession may not be fully captured in those dimensions. Faculty members may influence the practice of medicine and improve the care of patients yet not obtain traditional measures of achievement through publications, grants, or teaching awards. With this problem in mind, at the University of Toronto Faculty of Medicine, the promotions committee developed and implemented a promotions criterion called Creative Professional Activity (CPA) to recognize and reward a variety of types of academic endeavors that have a demonstrable impact on medical practice and care. CPA comprises three activities: professional innovation, exemplary practice, and contributions to the development of the discipline. In this article, the authors define CPA, provide illustrative case examples, describe how faculty members document CPA, and report the use of this promotions criterion in the Department of Medicine over the last decade. The challenges of implementing CPA as a promotion criterion are described. CPA is consistent with the Department of Medicine's goal of achieving excellence through original research, education, or creative work that advances the care of patients.

Consistency of standards and stability of pass/fail decisions with examinee-based standard-setting methods in a small-scale objective structured clinical examination.

PROBLEM STATEMENT AND BACKGROUND: The apparent feasibility and the face validity of the examinee-based methods such as the borderline-group methods provide support for their increasing adoption by health profession schools. Before that can occur, however, more information on the quality of the standards produced by these techniques is required. The purpose of the present study was to assess the quality of the standards produced on a small-scale objective structured clinical examination (OSCE) by the borderline-group and contrasting-groups examinee-based standard-setting procedures. METHOD: These two examinee-based criterion-referenced standard-setting procedures were done for an undergraduate fourth-year surgical OSCE and the consistency of the standards and the decisions arising from the standards were assessed. RESULTS: Both techniques provided consistent and realistic standards. CONCLUSIONS: There is sufficient theoretical and empirical evidence to support the use of examinee-based standard-setting techniques in small-scale OSCEs that use expert examiners.

Effect of an undergraduate medical curriculum on students' self-directed learning.

PURPOSE: Lifelong, self-directed learning (SDL) has been identified as an important ability for medical graduates. To evaluate the effect of the University of Toronto Faculty of Medicine's revised undergraduate medical curriculum on students' SDL, a cross-sectional study was conducted. METHOD: A questionnaire package was mailed to 280 randomly selected students, 70 from each of the four years of the curriculum. The package contained the two most widely recognized, extensively used, and validated instruments of SDL (Guglielmino's 58-item Self-Directed Learning Readiness Scale and Oddi's 24-item Continuous Learning Inventory) and Ryan's two-part Self-Assessment Questionnaire. An identification number and sociodemographic questions were included with the questionnaires. Data analysis was completed using chi-square for differences of proportions, analysis of variance for differences between means, and linear regression for trends. RESULTS: A total of 250 (89.3%) complete questionnaire packages were returned. No significant trend in SDL was evident by curriculum year, and similar SDL levels were observed for women and men. However, a significant positive trend in SDL was found with the highest level of premedical education achieved (undergraduate only, masters, or doctoral). Further, students' perceptions concerning the importance of SDL decreased according to year in the curriculum. CONCLUSION: This study found no evidence that students' self-reported SDL is positively influenced by the current undergraduate medical curriculum at the University of Toronto Faculty of Medicine.

The effect of incorporating normative data into a criterion-referenced standard setting in medical education.

PURPOSE: Determining standards for assessing clinical performance is a controversial issue. Purely item-based methods such as the Angoff method often produce unrealistic judgments, even when used by experienced judges. The rather unstudied compromise methods combine absolute and relative judgments and thereby incorporate normative data into criterion-based standard-setting judgments. The purpose of this study was to compare the quality and implications of standards set by three methods used for the Objective Structured Clinical Examination (OSCE). METHOD: Ninety-six judges set standards for 36 surgical year-4 undergraduate OSCE stations. All judges had normative student performance data when judgments were made with the Angoff, Ebel, or Hofstee methods. RESULTS: The Hofstee method gave more realistic cutoff scores and standard errors and better Meskauskas and Jaeger indices than the Angoff and Ebel methods. CONCLUSIONS: Medical educators setting standards for an OSCE should consider adopting the Hofstee method.

A sequenced OSCE for licensure: administrative issues, results and myths.

In response to stakeholder demands for a more cost-effective clinical examination, the Medical Council of Canada adopted a sequenced format for the OSCE component of its licensure examination. The sequenced OSCE was administered in 1997 at 14 sites and assessed 1,796 test takers. The 10-station screening test had an alpha = 0.66 (M = 61.3%, SD = 4.7%). The fail rate of 1.7% for Canadian first-time takers was the lowest since 1992. Significant savings were realized despite costs incurred by the new format. The logistical problems that were encountered were largely due to the constraints of administering a multi-site OSCE. Although the sequenced format was cost effective and psychometrically acceptable, the response of many test takers and faculty members was negative. Consequently, it is the logistical and political lessons that may be the most generalizable.

Evaluating medical grand rounds.

INTRODUCTION: Since January 2000, standard presenter evaluation forms have been made available to grand rounds organizers in the Department of Medicine, University of Toronto. During the 2000-2001 academic year, effort was directed at the accumulation of evidence for the validity of the results generated. METHODS: Two issues were addressed: the integrity or coherence of the form itself and the number of forms or evaluations required to achieve a stable estimate of the construct "presenter effectiveness" for an individual presenter. RESULTS: Positive evidence relating to the integrity of the form is presented and the number of evaluations or ratings required to provide a stable estimate of presenter effectiveness is suggested. DISCUSSION: Most presenters' ratings were distributed in a narrow range. Ranking of individual presentations would require exceptionally high precision. Separation into groups requires less precision. This type of classification appears sufficient to enable planning decisions.

Using the Judgments of Physician Examiners in Setting the Standards for a National Multi-center High Stakes OSCE.

In 1994 and 1995, the Medical Council of Canada used an innovative approach to set the pass mark on its large scale, multi-center national OSCE which is designed to assess basic clinical and communication skills in physicians in Canada after 15 months of post-graduate medical training. The goal of this article is to describe the new approach and to present the experience with the method during its first two years of operation. The approach utilizes the global judgments of the physician examiners at each station to identify the candidates with borderline performances. The scores of the candidates whose performances are judged to be borderline are summed for each station, yielding an initial passing score for all stations and then the examination as a whole. The latter score is then adjusted upward one standard error of measurement for the final passing score and is used as one of the criteria to pass the examination. Based on the results to date, the new approach has worked well. The advantages, disadvantages and areas of possible refinement for the approach are reviewed.