Improving communication skill training in patient centered medical practice for enhancing rational use of laboratory tests: The core of bioinformation for leveraging stakeholder engagement in regulatory science.

Requests for laboratory tests are among the most relevant additional tools used by physicians as part of patient's health problemsolving. However, the overestimation of complementary investigation may be linked to less reflective medical practice as a consequence of a poor physician-patient communication, and may impair patient-centered care. This scenario is likely to result from reduced consultation time, and a clinical model focused on the disease. We propose a new medical intervention program that specifically targets improving the patient-centered communication of laboratory tests results, the core of bioinformation in health care. Expectations are that medical students training in communication skills significantly improve physicians-patient relationship, reduce inappropriate use of laboratorial tests, and raise stakeholder engagement

Fludarabine induces apoptosis in chronic lymphocytic leukemia - the role of P53, Bcl-2, Bax, Mcl-1, and Bag-1 proteins

The expression of P53, Bcl-2, Bax, Bag-1, and Mcl-1 proteins in CD5/CD20-positive B-chronic lymphocytic leukemia (B-CLL) cells from 30 typical CLL patients was evaluated before and after 48 h of incubation with 10-6 M fludarabine using multiparametric flow cytometric analysis. Protein expression was correlated with annexin V expression, Rai modified clinical staging, lymphocyte doubling time, and previous treatment. Our main goal was to determine the predictive value of these proteins in CLL cells in terms of disease evolution. Bcl-2 expression decreased from a median fluorescence index (MFI) of 331.71 ± 42.2 to 245.81 ± 52.2 (P < 0.001) after fludarabine treatment, but there was no difference between viable cells (331.57 ± 44.6 MFI) and apoptotic cells (331.71 ± 42.2 MFI) before incubation (P = 0.859). Bax expression was higher in viable cells (156.24 ± 32.2 MFI) than in apoptotic cells (133.56 ± 35.7 MFI) before incubation, probably reflecting defective apoptosis in CLL (P = 0.001). Mcl-1 expression was increased in fludarabine-resistant cells and seemed to be a remarkable protein for the inhibition of the apoptotic process in CLL (from 233.59 ± 29.8 to 252.04 ± 35.5; P = 0.033). After fludarabine treatment, Bag-1 expression was increased in fludarabine-resistant cells (from 425.55 ± 39.3 to 447.49 ± 34.5 MFI, P = 0.012), and interestingly, this higher expression occurred in patients who had a short lymphocyte doubling time (P = 0.022). Therefore, we could assume that Bag-1 expression in such situation might identify CLL patients who will need treatment earlier.Universidade Federal de Minas Gerais Hospital das Clínicas Serviço de Hematologia e HemoterapiaUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Disciplina de Hematologia e HemoterapiaUNIFESP, EPM, Disciplina de Hematologia e HemoterapiaSciEL

Prognosis related to staging systems for chronic lymphocytic leukemia

CONTEXT: Chronic lymphocytic leukemia (CLL) is a clonal lymphoproliferative disorder, characterized by B lymphocytic proliferation. CLL is the most frequent adult leukemia in Western countries, accounting for 25 to 30% of all white leukemic patients. OBJECTIVE: To evaluate clinical and staging characteristics in prognosis of chronic lymphocytic leukemia. DESIGN: Evaluation of clinical-staging data. SETTING: Universidade Federal de São Paulo (UNIFESP) - Escola Paulista de Medicina / Universidade de Alfenas. SAMPLE: 73 patients diagnosed from 1977 to 1994. MAIN MEASUREMENTS: Sex, ethnic origin, age, lymphadenopathy, splenomegaly, hepatomegaly, three or more areas of lymphoid enlargement, hemoglobin (g/dl), lymphocytes/mm³, Platelets/mm³ RESULTS: Mean survival of patients was 76 months, median age was 65 years, ranging from 33 to 87. Forty-four patients (60.3%) were male and 29 (39.7%) female. CONCLUSION: The Binet system determined a better prognosis than Rai.CONTEXTO: Diversas variáveis clínicas se relacionam ao prognóstico na leucemia linfocítica crônica; no entanto, o estadiamento de Binet determina melhor o prognóstico do que o estadiamento de Rai e Rai modificado. OBJETIVO: Avaliar características clínicas e laboratoriais no prognóstico da leucemia linfocítica crônica. TIPO DE ESTUDO: Estudos de correlação. LOCAL: Universidade Federal de São Paulo (UNIFESP) - Escola Paulista de Medicina / Universidade de Alfenas. PARTICIPANTES: 73 patients diagnosticados entre 1977 e 1994. VARIÁVEIS ESTUDADAS: Sexo, origem étnica, idade, linfadenomegalia, esplenomegalia, hepatomegalia, três ou mais áreas com aumento linfóide, hemoglobina, linfocitos, plaquetas. RESULTADOS: A sobrevida média dos pacientes foi 76 meses, idade média de 65 anos, variando de 33 a 87 anos. Quarenta e quatro pacientes (60,3%) eram do sexo masculino e 29 (39,7%) do sexo feminino. A análise univariada mostrou que o nível de hemoglobina (P = 0,001), número de plaquetas (P = 0,03), linfocitose periférica (P = 0,03), número de áreas linfóides acometidas (P = 0,01), assim como os estadiamentos de Rai (P = 0,02), Rai modificado (0,007) e Binet (P = 0,003) relacionaram-se significantemente com a sobrevida. A análise multivariada, pela regressão de Cox, demonstrou que o sistema de Binet determina melhor o prognóstico do que os estadiamentos de Rai e Rai modificado. CONCLUSÃO: O estadiamento de Binet é melhor que o estadiamento de Rai e Rai modificado na determinação do prognóstico.Universidade de Alfenas Division of HematologyUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Division of HematologyUniversidade Federal de São Paulo (UNIFESP) Escola Paulista de Medicina Division of EpidemiologyUNIFESP, EPM, Division of HematologyUNIFESP, EPM, Division of EpidemiologySciEL

Erratum to: The effect of self-explanation of pathophysiological mechanisms of diseases on medical students’ diagnostic performance

In the initial online publication, the name of author Alexandre Sampaio Moura was incorrectly captured as Alexandre Sampaio de Moura. This has now been corrected.</p

USING ENTRUSTABLE PROFESSIONAL ACTIVITIES IN THE DESIGN OF THREE NEW HEALTHCARE UNDERGRADUATE PROGRAMS: BIOMEDICINE, NURSING AND PSYCHOLOGY

Entrustable Professional Activities (EPAs) can be defined as a unit of professional practice that can be entrusted to a trainee after they have obtained adequate competency. EPAs integrate multiple competencies from several domains and are very useful in designing competency-based curricula. Using EPAs to design medical curricula has been widely described, but their application to curriculum design of other health-related undergraduate programs is scarce. This manuscript critically assesses an educational planning experience of using EPAs to simultaneously design three healthcare undergraduate programs (nursing, biomedicine and psychology) at Faculdade Santa Casa BH, Minas Gerais, Brazil. We present the EPAs for each program, curricula frameworks, educational strategies, and assessment methods. Expert groups of professors and educational specialists defined the core professional activities that would be directly assessed and entrusted to trainees from the three different programs. The expert group then defined the required knowledge, skills, and attitudes for each EPA and selected the appropriate assessment tools to be used in entrustment decisions. The expected entrustment level for each training phase guided the course’s distribution of core and elective courses. The experience of designing a curriculum using EPAs was successful and helped focus on the core activities of each profession. It also provided an opportunity to reflect upon formative and summative assessments throughout the course bringing the challenge of reorienting our teaching practices and assessment approaches. Designing undergraduate curricula of health-related professions using EPAs is feasible and might help operationalize competency-based curricula.  Article visualizations

The development of self-regulated learning during the pre-clinical stage of medical school: a comparison between a lecture-based and a problem based curriculum

Society expects physicians to always improve their competencies and to be up to date with developments in their field. Therefore, an important aim of medical schools is to educate future medical doctors to become self-regulated, lifelong learners. However, it is unclear if medical students become better self-regulated learners during the pre-clinical stage of medical school, and whether students develop self-regulated learning skills differently, dependent on the educational approach of their medical school. In a cross-sectional design, we investigated the development of 384 medical students’ self-regulated learning skills with the use of the Self-Regulation of Learning Self-Report Scale. Next, we compared this development in students who enrolled in two distinct medical curricula: a problem-based curriculum and a lectured-based curriculum. Analysis showed that more skills decreased than increased during the pre-clinical stage of medical school, and that the difference between the curricula was mainly caused by a decrease in the skill evaluation in the lecture-based curriculum. These findings seem to suggest that, irrespective of the curriculum, self-regulated learning skills do not develop during medical school

'Immunising' physicians against availability bias in diagnostic reasoning: A randomised controlled experiment

Background: Diagnostic errors have often been attributed to biases in physicians' reasoning. Interventions to 'immunise' physicians against bias have focused on improving reasoning processes and have largely failed. Objective: To investigate the effect of increasing physicians' relevant knowledge on their susceptibility to availability bias. Design, settings and participants: Three-phase multicentre randomised experiment with second-year internal medicine residents from eight teaching hospitals in Brazil. Interventions: Immunisation: Physicians diagnosed one of two sets of vignettes (either diseases associated with chronic diarrhoea or with jaundice) and compared/contrasted alternative diagnoses with feedback. Biasing phase (1 week later): Physicians were biased towards either inflammatory bowel disease or viral hepatitis. Diagnostic performance test: All physicians diagnosed three vignettes resembling inflammatory bowel disease, three resembling hepatitis (however, all with different diagnoses). Physicians who increased their knowledge of either chronic diarrhoea or jaundice 1 week earlier were expected to resist the bias attempt. Main outcome measurements: Diagnostic accuracy, measured by test score (range 0-1), computed for subjected-to-bias and not-subjected-to-bias vignettes diagnosed by immunised and not-immunised physicians. Results: Ninety-one residents participated in the experiment. Diagnostic accuracy differed on subjected-to-bias vignettes, with immunised physicians performing better than non-immunised physicians (0.40 vs 0.24; difference in accuracy 0.16 (95% CI 0.05 to 0.27); p=0.004), but not on not-subjected-to-bias vignettes (0.36 vs 0.41; difference -0.05 (95% CI -0.17 to 0.08); p=0.45). Bias only hampered non-immunised physicians, who performed worse on subjected-to-bias than not-subjected-to-bias vignettes (difference -0.17 (95% CI -0.28 to -0.05); p=0.005); immunised physicians' accuracy did not differ (p=0.56). Conclusions: An intervention directed at increasing knowledge of clinical findings that discriminate between similar-looking diseases decreased physicians' susceptibility to availability bias, reducing diagnostic errors, in a simulated setting. Future research needs to examine the degree to which the intervention benefits other disease clusters and performance in clinical practice. Trial registration number: 68745917.1.1001.0068

Impacto do Treinamento de Habilidades de Comunicação e do Registro Médico na Prática do Método Clínico de Atendimento Integral à Pessoa

RESUMO Introdução A prática do atendimento clínico integral à pessoa é um desafio enfrentado pelo educador médico, por instituições de ensino e por pesquisadores que tentam contribuir para que os estudantes desenvolvam competências educacionais que sintetizem conhecimentos, habilidades e atitudes para esse modelo. Objetivo O objetivo deste estudo foi avaliar o impacto do treinamento de habilidades de comunicação na prática do método clínico de atendimento integral à pessoa, com ou sem o uso de registro específico para o atendimento. Métodos Participaram do estudo 46 estudantes do sétimo período do curso de Medicina da Universidade Federal de Minas Gerais (UFMG). Uma combinação de atividades educacionais foi utilizada para propiciar a aquisição de habilidades de comunicação para o atendimento clínico integral à pessoa, como modeling example, seguido de reflexão individual e discussão, aula expositiva interativa e uso de formulário de registro específico para o atendimento clínico integral à pessoa (RACIP). O estudo foi dividido em quatro fases: (1) pré-treinamento: filmagem de atendimento clínico em ambiente simulado, realizado pelos 46 estudantes, com a utilização do modelo de registro de consulta vigente no HC-UFMG; (2) treinamento: os estudantes foram divididos em três grupos: G1 – submetidos à atividade educacional não relacionada ao atendimento clínico; G2 e G3 – submetidos a treinamento de habilidades de comunicação; (3) avaliação: filmagem de consulta em ambiente simulado, realizada por todos os grupos, sendo que G1 e G3 utilizaram o RACIP, e G2, o modelo de registro vigente; (4) feedback e oportunidade de mesma aprendizagem para todos os grupos. Os vídeos dos atendimentos clínicos realizados pelos estudantes, pré e pós-treinamento, foram avaliados por uma banca constituída por três avaliadores, utilizando-se o instrumento AVACIP (avaliação de atendimento clínico integral à pessoa), levando-se em consideração cinco domínios: início da consulta; expectativas do paciente sobre a consulta; perspectiva do paciente sobre sua doença; comportamento e hábitos de vida; uso de propedêutica complementar e aliança terapêutica. Resultado O escore total de atitudes positivas de cada grupo foi maior na Fase 3 em relação à 1 (p = 0,001), mostrando que todas as estratégias promoveram a melhora das habilidades de comunicação, mas não houve diferença entre os grupos em cada fase (p > 0,310). Quando os escores foram analisados por domínio, observou-se que o G3 apresentou melhor desempenho do que os outros. Conclusão O treinamento de habilidades em comunicação e o uso de modelo de registro específico para o atendimento melhoram o desempenho dos estudantes em relação ao atendimento clínico integral à pessoa