Patient and parent perspectives on transition from paediatric to adult healthcare in rheumatic diseases: an interview study.

OBJECTIVES: To describe the experiences, priorities, and needs of patients with rheumatic disease and their parents during transition from paediatric to adult healthcare. SETTING: Face-to-face and telephone semistructured interviews were conducted from December 2018 to September 2019 recruited from five hospital centres in Australia. PARTICIPANTS: Fourteen young people and 16 parents were interviewed. Young people were included if they were English speaking, aged 14-25 years, diagnosed with an inflammatory rheumatic disease (eg, juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, panniculitis, familial Mediterranean fever) before 18 years of age. Young people were not included if they were diagnosed in the adult setting. RESULTS: We identified four themes with respective subthemes: avoid repeat of past disruption (maintain disease stability, preserve adjusted personal goals, protect social inclusion); encounter a daunting adult environment (serious and sombre mood, discredited and isolated identity, fear of a rigid system); establish therapeutic alliances with adult rheumatology providers (relinquish a trusting relationship, seek person-focused care, redefine personal-professional boundaries, reassurance of alternative medical supports, transferred trust to adult doctor) and negotiate patient autonomy (confidence in formerly gained independence, alleviate burden on patients, mediate parental anxiety). CONCLUSIONS: During transition, patients want to maintain disease stability, develop a relationship with their adult provider centralised on personal goals and access support networks. Strategies to comprehensively communicate information between providers, support self-management, and negotiate individualised goals for independence during transition planning may improve satisfaction, and health and treatment outcomes

The experience of patients admitted to hospital with acute low back pain : a qualitative study

Aim: To understand the patient experience of being admitted to hospital with acute low back pain (LBP), with a view to developing suggestions for care and LBP management guidelines. Method: Interpretive phenomenological analysis (IPA) was adopted to examine semi-structured interviews from patients admitted to hospital with acute LBP. Sampling continued until thematic saturation was reached (n = 14). Data were analyzed using the Framework Method, so that data from multiple participants could be systematically summarized, compared, and analyzed. Results: Four themes were identified: pain and helplessness, desire for validation, interactions with healthcare teams, and a return to pre-morbid identity and roles. Patients’ initial presentation to hospital was characterized by severe pain, disability and difficulty in communicating their illness experience. Patients expected doctors to investigate for an underlying cause of the back pain. To recover, they were required to navigate a system they did not understand, interacting with healthcare workers who seemed to operate independently rather than as a team. Patients viewed medical treatment as a means of returning to pre-morbid activities of daily living, roles and relationships. Using these themes, a model of the inpatient journey was developed. Conclusion: We have described new patient insights which highlight how the hospital environment adds unique challenges to managing acute LBP. Several suggestions for acute LBP management guidelines are made: developing lay summaries for patients, including methods for communicating the team structure and roles to patients, and ensuring all members of treating teams are educated to ensure guidelines are consistently implemented

A patient-centered approach to developing entrustable professional activities

PURPOSE: The medical education community is rapidly accepting the use of entrustable professional activities (EPAs) as a means of assessing residents. Stakeholder engagement is advised in developing EPAs, but no studies have investigated the role of patient input. In this qualitative study, the authors investigated what patient input may add to designing a patient-centered EPA. METHOD: The authors chose “management of acute low back pain (LBP)” as a common, important clinical task on which to base the patient-centered EPA. In 2015, 14 patients who presented to a teaching hospital with acute LBP participated in semistructured interviews exploring their illness experience and expectations of doctors. Clinicians representing multiple disciplines participated in a focus group. The authors used the Framework Method to analyze data, identifying and developing themes, similarities, and differences between patient and clinician input. They used the findings to develop the EPA. Through an iterative procedure of data review and tracking data sources, they determined how patient and clinician input informed each EPA descriptor. RESULTS: Drawing from their firsthand experience of LBP, patients described unique expectations of trainees which directly informed EPA descriptors. For example, the authors primarily used patients’ detailed descriptions of desirable and observable trainee behaviors to inform the required attitudes descriptor. CONCLUSIONS: Patients can provide unique contributions, complementary to those of clinicians, to EPAs. Consultations with patients led to the development of a patient-centered EPA, which aligned best clinical practice with patient expectations. Educators seeking to apply patient-centered care to EPA development could adopt a similar approach

The ABCs of entrustable professional activities : an overview of 'Entrustable Professional Activities' in medical education

Consultants regularly need to decide whether a trainee can be entrusted to perform a clinical activity independently. 'Entrustable Professional Activities' (EPAs) provide a framework for justifying and better utilising supervisor entrustment decisions for trainee feedback and assessment in the workplace. Since being proposed by Olle ten Cate in 2005, EPAs are emerging as an integral part of many international medical curricula, and are being considered by the Royal Australasian College of Physicians in the current review of physician training. EPAs are defined as tasks or responsibilities that can be entrusted to a trainee once sufficient competence is reached to allow for unsupervised practice. An example might be to entrust a trainee to 'Initiate and co-ordinate care of the palliative patient' with only off-site or indirect supervision. Rather than attempting to directly measure each of the many separate competencies required to undertake such a complex task, EPAs direct the trainee and supervisor's attention to the trainee's performance in a limited number of selected, representative, important day-to-day activities. EPA based assessment is gaining momentum, amongst significant concerns regarding feasibility of implementation. While the optimal process for designing and implementing EPAs remains to be determined, it is an assessment strategy where the over-arching goal of optimal patient care remains in clear sight. This review explores the central role of trust in medical training, the case for EPAs, and potential barriers to implementing EPAs based assessment

Enhancing the defensibility of examiners\u27 marks in high stake OSCEs

Background: Most assessments in health professions education consist of knowledge-based examinations as well as practical and clinical examinations. Among the most challenging aspects of clinical assessments is decision making related to borderline grades assigned by examiners. Borderline grades are commonly used by examiners when they do not have sufficient information to make clear pass/fail decisions. The interpretation of these borderline grades is rarely discussed in the literature. This study reports the application of the Objective Borderline Method (version 2, henceforth: OBM2) to a high stakes Objective Structured Clinical Examination undertaken at the end of the final year of a Medicine program in Australia. Methods: The OBM2 uses all examination data to reclassify borderline grades as either pass or fail. Factor analysis was used to estimate the suitability of data for application of OBM2. Student\u27s t-tests, utilising bootstrapping, were used to compare the OBM2 with \u27traditional\u27 results. Interclass correlations were used to estimate the association between the grade reclassification and all other grades in this examination. Results: The correlations between scores for each station and pass/fail outcomes increased significantly after the mark reclassification, yet the reclassification did not significantly impact on students\u27 total scores. Examiners, students and program leaders expressed high levels of satisfaction and the Faculty\u27s Curriculum Development Committee has decided that the OBM2 will be used for all future clinical examinations. Implications of the OBM2 are discussed. Conclusions: The OBM2 provides a feasible, defensible and acceptable solution for classification of borderline grades as either pass or fail

Borderline grades in high stakes clinical examinations: resolving examiner uncertainty

Abstract Background Objective Structured Clinical Exams are used to increase reliability and validity, yet they only achieve a modest level of reliability. This low reliability is due in part to examiner variance which is greater than the variance of students. This variance often represents indecisiveness at the cut score with apparent confusion over terms such as “borderline pass”. It is amplified by a well reported failure to fail. Methods A borderline grade (meaning performance is neither a clear pass nor a clear fail) was introduced in a high stakes undergraduate medical clinical skills exam to replace a borderline pass grade (which was historically resolved as 50%) in a 4 point scale (distinction, pass, borderline, fail). Each Borderline grade was then resolved into a Pass or Fail grade by a formula referencing the difficulty of the station and the performance in the same domain by the student in other stations. Raw pass or fail grades were unaltered. Mean scores and 95%CI were calculated per station and per domain for the unmodified and the modified scores/grades (results are presented on error bars). To estimate the defensibility of these modifications, similar analysis took place for the P and the F grades which resulted from the modification of the B grades. Results Of 14,634 observations 4.69% were Borderline. Application of the formula did not impact the mean scores in each domain but the failure rate for the exam increased from 0.7 to 4.1%. Examiners and students expressed satisfaction with the Borderline grade, resolution formula and outcomes. Mean scores (by stations and by domains respectively) of students whose B grades were modified to P were significantly higher than their counterparts whose B grades were modified to F. Conclusions This study provides a feasible and defensible resolution to situations where the examinee’s performance is neither a clear pass nor a clear fail, demonstrating the application of the resolution of borderline formula in a high stakes exam. It does not create a new performance standard but utilises real data to make judgements about these small number of candidates. This is perceived as a fair approach to Pass/Fail decisions

Cut-scores revisited: feasibility of a new method for group standard setting

Abstract Background Standard setting is one of the most contentious topics in educational measurement. Commonly-used methods all have well reported limitations. To date, there is not conclusive evidence suggesting which standard setting method yields the highest validity. Methods The method described and piloted in this study asked expert judges to estimate the scores on a real MCQ examination that they consider indicated a clear pass, clear fail, and pass mark for the examination as a whole. The mean and SD of the judges responses to these estimates, Z scores and confidence intervals were used to derive the cut-score and the confidence in it. Results In this example the new method’s cut-score was higher than the judges’ estimate. The method also yielded estimates of statistical error which determine the range of the acceptable cut-score and the estimated level of confidence one may have in the accuracy of that cut-score. Conclusions This new standard-setting method offers some advances, and possibly advantages, in that the decisions being asked of judges are based on firmer constructs, and it takes into account variation among judges

Curriculum mapping for health professions education : a typology

Introduction: Across higher education, curriculum mapping has attracted great interest, partly driven by the need to map graduate competencies to learning and assessment for quality assurance and accreditation. Other drivers have included the need to: a) provide tools for curriculum design and renewal, b) improve communication amongst teachers and curriculum developers and c) support learning by informing students about the scope and sequence of their programs. Those embarking on curriculum mapping have sought clarification about what elements of the curriculum should be mapped, how to develop their own map or whether they should adopt externally available products. During our combined experience of mapping six different medical programs over the course of 15 years, we have frequently sought answers to these questions. However, due to the many and varying types of curriculum maps and curriculum-mapping processes that are described in the literature, answers have not been readily forthcoming. Methods: We conducted a comprehensive review of the higher education—including health professions—literature to develop a four-dimensional typology for curriculum maps, which details features related to their purpose, product, process and display. The typology was validated by testing the parameters against six curriculum maps from medical schools around Australia. Results: Using a synthesis of 265 higher education publications, we created a structured framework and common language around the four dimensions of curriculum mapping. Discussion: The typology can be used by health professions educators to make key decisions about the many curriculum map options available

Metastatic solid tumors to the jaw and oral soft tissue: A retrospective clinical analysis of 44 patients from a single institution

PURPOSE: Metastatic solid tumors to the oral cavity are rare, frequently indicative of an end-stage disease process, and associated with poor survival rates. We performed a 20-year retrospective clinical analysis of our institution’s cases of solid metastases to the oral cavity, and investigated these patients’ clinical outcomes. MATERIAL AND METHODS: A retrospective study of patients with metastatic solid tumors to the oral cavity over a 20-year period (October 1996 to September 2015) was conducted at Memorial Sloan Kettering Cancer Center. Patients were selected if they had a histopathologically confirmed diagnosis. Demographic, pathologic, and clinical information were reviewed to identify patient outcomes. RESULTS: A total of 44 patients with metastatic non-melanocytic non-hematopoietic tumor to the oral cavity were identified: 24 males and 20 females (39 adults and 5 children) with a mean age of 54.3 years. In all, 24 cases involved the jaw and 20 cases involved the oral soft tissue. Eight patients (18.2%) had oral cavity metastases as the first indication of an occult malignancy. In adult patients, the common primary sites were the lungs (n = 9, 20%), kidney (n = 7, 16%), breast (n = 5, 11%), and colon (n = 4, 9%); and in pediatric patients the adrenal gland (3/5) was the most common site. Of the adult patients, 33 (84.6%) died of disease. From the time of metastasis diagnosis, patients with jaw metastases had a median and mean survival of 12 months and 27.7 months, respectively. In comparison, patients with oral soft tissue metastases had a median survival time of 5 months, and mean of 8 months. One pediatric patient (20%) died of disease 8 months after metastasis diagnosis. CONCLUSION: Metastatic solid tumors to the oral cavity can be the first sign of a malignancy. Pediatric patients with oral cavity metastases have a better prognosis compared to adult patients. In this series, adults with oral soft tissue involvement had shorter survival times compared to patients with jaw involvement