Le rôle fondamental de l’observation directe dans la décision de confier une responsabilité professionnelle

Background: Entrustment decisions may be retrospective (based on past experiences with a trainee) or real-time (based on direct observation). We investigated judgments of entrustment based on assessor prior knowledge of candidates and based on systematic direct observation, conducted in an objective structured clinical exam (OSCE). Methods: Sixteen faculty examiners provided 287 retrospective and real-time entrustment ratings of 16 cardiology trainees during OSCE stations in 2019 and 2020. Reliability and validity of these ratings were assessed by comparing correlations across stations as a measure of reliability, differences across postgraduate years as an index of construct validity, correlation to standardized in-training exam (ITE) as a measure of criterion validity, and reclassification of entrustment as a measure of consequential validity. Results: Both retrospective and real-time assessments were highly reliable (all intra-class correlations >0.86). Both increased with year of postgraduate training. Real-time entrustment ratings were significantly correlated with standardized ITE scores; retrospective ratings were not. Real-time ratings explained 37% (2019) and 46% (2020) of variance in examination scores vs. 21% (2019) and 7% (2020) for retrospective ratings. Direct observation resulted in a different level of entrustment compared with retrospective ratings in 44% of cases (p = <0.001). Conclusions: Ratings based on direct observation made unique contributions to entrustment decisions.Contexte : La décision de confier une activité peut être rétrospective (basée sur les expériences antérieures avec un apprenant) ou en temps réel (basée sur l’observation directe). Nous avons étudié les évaluations de niveaux de confiance fondées sur des interactions antérieures des candidats par les évaluateurs et celles fondées sur l’observation directe systématique, dans le cadre d’un examen clinique objectif structuré (ECOS). Méthodes : Seize évaluateurs du corps professoral ont fourni 287 évaluations rétrospectives et en temps réel du niveau de confiance faites lors des stations d’ECOS en 2019 et 2020 concernant 16 stagiaires en cardiologie. La fiabilité et la validité de ces évaluations ont été analysées en comparant les corrélations entre les stations comme mesure de la fiabilité, les différences entre les années d’études postdoctorales comme indice de la validité de construit, la corrélation avec l’examen normalisé en cours de formation (ITE) comme mesure de la validité de critère, et le reclassement des évaluations de la confiance comme mesure de la validité corrélative. Résultats : Les évaluations rétrospectives et en temps réel étaient toutes les deux très fiables (toutes les corrélations intra-classes >0,86). Les deux augmentaient avec le niveau de formation postdoctorale. Les évaluations de la confiance en temps réel étaient significativement corrélées aux scores de l’examen normalisé en cours de formation; les évaluations rétrospectives ne l’étaient pas. Les évaluations en temps réel expliquaient 37 % (2019) et 46 % (2020) de la variance des notes d’examen, contre 21 % (2019) et 7 % (2020) pour les évaluations rétrospectives. L’observation directe a permis de reclasser 44 % des évaluations rétrospectives de la confiance (p=<0,001 dans les deux cas). Conclusion : Les évaluations basées sur l’observation directe contribuent de façon importante à la décision de confier une activité

Checklists improve experts' diagnostic decisions

Context Checklists are commonly proposed tools to reduce error. However, when applied by experts, checklists have the potential to increase cognitive load and result in expertise reversal'. One potential solution is to use checklists in the verification stage, rather than in the initial interpretation stage of diagnostic decisions. This may avoid expertise reversal by preserving the experts' initial approach. Whether checklist use during the verification stage of diagnostic decision making improves experts' diagnostic decisions is unknown. Methods Fifteen experts interpreted 18 electrocardiograms (ECGs) in four different conditions: undirected interpretation; verification without a checklist; verification with a checklist, and interpretation combined with verification with a checklist. Outcomes included the number of errors, cognitive load, interpretation time and interpretation length. Outcomes were compared in two analyses: (i) a comparison of verification conditions with and without a checklist, and (ii) a comparison of all four conditions. Standardised scores for each outcome were used to calculate the efficiency of a checklist and to weigh its relative benefit against its relative cost in terms of cognitive load imposed, interpretation time and interpretation length. Results In both analyses, checklist use was found to reduce error (more errors were corrected in verification conditions with checklists [0.29 +/- 0.77 versus 0.03 +/- 0.61 errors per ECG], and fewer net errors occurred in all conditions with checklists [0.39 +/- 1.14 versus 1.04 +/- 1.49 errors per ECG];

Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam

Background Few studies have investigated whether clinicians can use checklists to verify their diagnostic decisions. Checklists may improve accuracy by prompting clinicians to reconsider or recollect information but might impair decision making by adding to clinicians' cognitive load. This study assessed whether checklists improve cardiac exam diagnostic accuracy, and whether this benefit is dependent on collecting additional information. Methods 191 internal medicine residents examined a cardiopulmonary simulator. They provided a diagnosis, subjective rating of certainty, and key findings before and after using a checklist. Residents were randomised; half were allowed access to the simulator and half were prohibited access to the simulator while using the checklist. Residents rated their cognitive load in each step: prechecklist diagnosis, checklist use and postchecklist diagnosis. Result Verifying with a checklist resulted in improved diagnostic accuracy; 88 residents (46%) made the correct diagnosis before using the checklist compared with 97 (51%) afterwards, p=0.04. The benefit of checklist use was restricted to residents allowed to re-examine the simulator (10 changed to correct diagnosis and one to an incorrect diagnosis) whereas no net benefit was seen among residents unable to re-examine the simulator (two changed to a correct diagnosis and two to an incorrect diagnosis, p=0.03). Those able to re-examine the simulator were slightly more confident after checklist use, whereas those unable to re-examine were slightly less confident after checklist use (p=0.01). The opportunity to re-examine the simulator had no effect on the accuracy of key findings reported. Of the three steps, checklist use was associated with the lowest cognitive load (F-1,F-189=68

Investigation of Parameters that Affect Resin Swelling in Green Solvents

The influence of various physical and chemical factors on the swelling of polystyrene and PEG based resins in greener organic solvents has been systematically investigated. In general, chemical factors: the nature of the functionality/linker and the degree of loading were found to have a far larger influence on the swelling of the resins than physical parameters such as bead size. The results are interpreted in terms of Hansen solubility parameters for the solvents and there is evidence that some solvents interact with the polymeric core of a resin whilst others interact with the functionality. The results are extended to a study of the changes in resin swelling observed during both deprotection and chain elongation reactions during solid phase peptide synthesis

Designing systems for the care we need: A transformation journey in Southwestern Ontario.

Primary care is considered the foundation of any health system. In Ontario, Canada Bills 41 and 74 introduced in 2016 and 2019, respectively, aimed to move towards a primary care-focused and sustainable integrated care approach designed around the needs of local populations. These bills collectively set the stage for integrated care and population health management in Ontario, with Ontario Health Teams (OHTs) introduced as a model of integrated care delivery systems. OHTs aim to streamline patient connectivity through the healthcare system and improve outcomes aligned with the Quadruple Aim. When Ontario released a call for health system partners to apply to become an OHT, providers, administrators, and patient/caregiver partners from the Middlesex-London area were quick to respond. We highlight the critical elements and journey of the Middlesex-London Ontario Health Team since its start

Association between smoking, outcomes, and early clopidogrel use in patients with acute coronary syndrome:insights from the Global Registry of Acute Coronary Events

BACKGROUND: Smoking induces CYP1A2, thereby enhancing clopidogrel conversion to its active metabolite. We sought to determine the association between clopidogrel use and clinical outcomes in smokers versus nonsmokers with a broad spectrum of acute coronary syndrome (ACS). METHODS: We examined the association between early clopidogrel use in-hospital and 6-month outcomes among 44,426 patients with ACS in relation to smoking status in the Global Registry of Acute Coronary Events. We tested for heterogeneity of clopidogrel effect among smokers versus nonsmokers in separate multivariable models that adjusted for (1) established prognosticators in the Global Registry of Acute Coronary Events risk score and (2) independent predictors of major bleeding. RESULTS: Rates of in-hospital mortality, death/myocardial infarction, and major bleeding were 4.3%, 5.9%, and 2.5%, respectively. Current smokers (n = 12,149) were more likely to be younger men without documented vascular disease; had lower rates of hypertension, hyperlipidemia, and diabetes; and more frequently presented with ST elevation (all P \u3c .0001). Early clopidogrel use (55%) was associated with a reduction in the composite endpoint of mortality and myocardial infarction both in-hospital and at 6 months among current smokers and nonsmokers. There was no interaction between current smoking and clopidogrel use for ischemic endpoints. Major bleeding associated with early clopidogrel use was actually lower among current smokers compared with nonsmokers. CONCLUSIONS: Despite prior observations of smoking-enhanced clopidogrel effects, early clopidogrel use among smokers presenting with ACS compared with nonsmokers was not independently associated with a greater reduction in cardiovascular events. In contrast with nonsmokers, clopidogrel use among smokers was not associated with excess bleeding, perhaps because of unmeasured confounders

Comparison of heart team vs interventional cardiologist recommendations for the treatment of patients with multivessel coronary artery disease

Abstract: Importance: Although the heart team approach is recommended in revascularization guidelines, the frequency with which heart team decisions differ from those of the original treating interventional cardiologist is unknown. Objective: To examine the difference in decisions between the heart team and the original treating interventional cardiologist for the treatment of patients with multivessel coronary artery disease. Design, setting, and participants: In this cross-sectional study, 245 consecutive patients with multivessel coronary artery disease were recruited from 1 high-volume tertiary care referral center (185 patients were enrolled through a screening process, and 60 patients were retrospectively enrolled from the center's database). A total of 237 patients were included in the final virtual heart team analysis. Treatment decisions (which comprised coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy) were made by the original treating interventional cardiologists between March 15, 2012, and October 20, 2014. These decisions were then compared with pooled-majority treatment decisions made by 8 blinded heart teams using structured online case presentations between October 1, 2017, and October 15, 2018. The randomized members of the heart teams comprised experts from 3 domains, with each team containing 1 noninvasive cardiologist, 1 interventional cardiologist, and 1 cardiovascular surgeon. Cases in which all 3 of the heart team members disagreed and cases in which procedural discordance occurred (eg, 2 members chose coronary artery bypass grafting and 1 member chose percutaneous coronary intervention) were discussed in a face-to-face heart team review in October 2018 to obtain pooled-majority decisions. Data were analyzed from May 6, 2019, to April 22, 2020. Main outcomes and measures: The Cohen κ coefficient between the treatment recommendation from the heart team and the treatment recommendation from the original treating interventional cardiologist. Results: Among 234 of 237 patients (98.7%) in the analysis for whom complete data were available, the mean (SD) age was 67.8 (10.9) years; 176 patients (75.2%) were male, and 191 patients (81.4%) had stenosis in 3 epicardial coronary vessels. A total of 71 differences (30.3%; 95% CI, 24.5%-36.7%) in treatment decisions between the heart team and the original treating interventional cardiologist occurred, with a Cohen κ of 0.478 (95% CI, 0.336-0.540; P = .006). The heart team decision was more frequently unanimous when it was concordant with the decision of the original treating interventional cardiologist (109 of 163 cases [66.9%]) compared with when it was discordant (28 of 71 cases [39.4%]; P < .001). When the heart team agreed with the original treatment decision, there was more agreement between the heart team interventional cardiologist and the original treating interventional cardiologist (138 of 163 cases [84.7%]) compared with when the heart team disagreed with the original treatment decision (14 of 71 cases [19.7%]); P < .001). Those with an original treatment of coronary artery bypass grafting, percutaneous coronary intervention, and medication therapy, 32 of 148 patients [22.3%], 32 of 71 patients [45.1%], and 6 of 15 patients [40.0%], respectively, received a different treatment recommendation from the heart team than the original treating interventional cardiologist; the difference across the 3 groups was statistically significant (P = .002). Conclusions and relevance: The heart team's recommended treatment for patients with multivessel coronary artery disease differed from that of the original treating interventional cardiologist in up to 30% of cases. This subset of cases was associated with a lower frequency of unanimous decisions within the heart team and less concordance between the interventional cardiologists; discordance was more frequent when percutaneous coronary intervention or medication therapy were considered. Further research is needed to evaluate whether heart team decisions are associated with improvements in outcomes and, if so, how to identify patients for whom the heart team approach would be beneficial