Exploring the introduction of entrustment rating scales in an existing objective structured clinical examination

Background: The concept of EPAs is increasingly applied to assess trainees’ workplace performance by means of entrustment ratings. OSCEs assess performance in a simulated setting, and it is unclear whether entrustment ratings can be integrated into these exams. This study explores the introduction of an entrustment rating scale into an existing OSCE. Methods: A 6-point entrustment scale was added to the standard ratings in an OSCE administered prior to students’ final clerkship year in an undergraduate medical programme. Standard OSCE ratings assess clinical and communication skills. Assessors (n = 54) rated students’ performance (n = 227) on a diverse set of clinical tasks and evaluated the addition of entrustment scales to OSCEs. Descriptive and inferential statistics were calculated for analyses. Results: Student performance varied across the stations, as reflected in both the standard OSCE ratings and the added entrustment ratings. Students received generally high standard OSCE ratings, whereas entrustment ratings were more widely distributed. All students passed the OSCE, and only a small proportion of students did not reach the expected pass threshold of 60% on the standard ratings in the single stations. The proportion of students who did not reach the expected entrustment level in the respective stations was noticeably higher. Both the clinical and communication skill ratings were related to the entrustment rating in most OSCE stations. A majority of the assessors positively evaluated the addition of entrustment ratings into the OSCE. Discussion: The findings provide an empirical basis to broaden our understanding of the potential use of entrustment ratings in existing OSCEs. They provide directions for future, more specific studies. The ratings might be used for formative feedback on students’ readiness for workplace practice

Entrustable professional activities for Junior Brazilian Medical Students in community medicine

Background: Entrustable professional activities (EPAs) have been defined to promote the workplace participation of undergraduate medical students, generally in the context of high-income countries with a focus on the secondary and tertiary health care sectors. These EPAs have limited applicability to training and health care contexts in low- to middle-income countries that have a focus on primary health care, for instance, the context of community medicine. The purpose of this article is to report the process and results of defining EPAs for undergraduate medical training in a community health care setting. Methods: A modified Delphi study was performed to develop EPAs for the training of medical students in community medicine during their first and second years of education at the Marilia Medical School (FAMEMA), Brazil. The supervision level was operationalized in terms of a student's ability to perform the EPA autonomously in an effective and safe manner with supervision readily available on request. Panellists (9 physicians and 6 nurses) rated the completeness of the proposed list of EPAs and EPA categories on four-point Likert scales. The threshold for consensus among panellists was a mean content validity index of at least 80%. Results: Consensus was reached after two Delphi rounds, resulting in 11 EPAs for undergraduate medical education and training in community medicine. These EPAs were organized into three overarching EPA domains: integrality of care for individual health needs in all phases of the life cycle (5 EPAs), integrality of care for family health needs (3 EPAs), and integrality of care for community health needs (3 EPAs). For each EPA, descriptions of the following categories were created: title; specifications and limitations; conditions and implications of the entrustment decision; knowledge, skills, and attitudes; links to competencies; and assessment sources. Conclusion: The resulting 11 EPAs for training medical students in community medicine expand the application of the EPA framework to both early undergraduate medical education and the context of primary health care. This report can support and guide other medical schools in their attempts to train students in primary health care contexts and to incorporate EPAs into their curricula

Doctors on the move 2: a qualitative study on the social integration of middle eastern physicians following their migration to Germany

Background: The integration of immigrating physicians has become a challenge for many societies and health care systems worldwide. Facilitating the integration process may benefit both the uptaking country and the immigrating physicians. Previous studies have approached this problem from a system integration perspective. The present study explores the degree of social integration of an exemplary group of Middle Eastern physicians following their migration to Germany from an individual perspective. Methods: Based on social constructivist epistemology, a series of fifteen interviews and two focus groups with immigrated Middle Eastern physicians (n = 23, purposively sampled) were conducted between 2017 and 2020 in Germany. The audio recordings were transcribed, translated into English and analysed deductively based on Esser's model of social integration, consisting of four dimensions: acculturation, positioning, interaction and identification. Results: The social integration of the participants showed a multifaceted picture. The early phase was characterized by disorientation and trial and error. Cultural differences were of major importance. Acculturation was facilitated by German language acquisition and increased over time, although some cultural difficulties remained. Professional positioning was facilitated by the need for physicians and a relatively low-hurdle relicensing procedure. Interaction and identification depended on the efforts of the individual physicians. Conclusions: This study provides a comprehensive picture of the individual social integration of Middle Eastern physicians in Germany. Language and cultural adaptation are identified as being of primary importance. Social integration can be facilitated through orientation programmes or cross-cultural training that benefits the uptaking countries as well as the immigrating physicians

Clinical reasoning for acute dyspnoea: comparison between final-year medical students from discipline- and competency-based undergraduate programmes

Abstract: Clinical reasoning for acute dyspnoea: Comparison of final-year medical students from discipline- andcompetency-based undergraduate programmes. Background: The global shift to competency-based medical education aims to improve the performance of itstrainees, including in the key competency domain of clinical reasoning. However, research on whether such educationactually improves clinical reasoning is sparse. The purpose of this study is to compare assessed clinical reasoningperformance in digitally presented cases of acute dyspnoea between final-year medical students from a traditional,discipline-based and those from an integrated, competency-based undergraduate programme. Methods: A total of 60 medical students in their final-year clerkships participated in the study; 30 were from adiscipline-based programme, and 30 were from a competency-based programme of the same faculty. The studentscompleted a knowledge test consisting of 22 single choice items and a computer-based test of clinical reasoning withsix video-based case scenarios with different underlying diseases leading to dyspnoea. The operationalized measures ofclinical reasoning were the number and relevance of the diagnostic tests chosen, time to diagnosis and diagnosticaccuracy. Results: The two groups did not differ in their knowledge of the acute dyspnoea content domain. With regard toclinical reasoning, the selection of relevant tests, time required to make a diagnosis and accuracy of the diagnosisvaried across the six case scenarios in both groups. However, the results from the measures of the clinical reasoningprocess did not differ between the students from the two types of undergraduate medical programmes. No significantdifferences were found with regard to the selection of relevant diagnostic tests (M = 63.8% vs. M = 62.8%), the time toa diagnosis (M = 128.7 s vs. M = 136.4 s) or the accuracy of diagnosis (M = 82.2% vs. M = 77.0%). Conclusions: Key indicators of the clinical reasoning process, when assessed with objectively measured parameters,did not differ between final-year medical students from a traditional, discipline-based and those from an integrated,competency-based undergraduate programme in the domain of acute dyspnoea. The results substantiate and expandthose of previous studies based on subjective assessor ratings that showed limited change in the clinical reasoningperformance of medical students with competency-based undergraduate education

Wirkungen der L-Arginingabe bei immun-vermittelter akuter und chronischer Glomerulofibrose

Die fortschreitende Vermehrung extrazellulärer Matrixproteine ist zentrales Kennzeichen von chronisch-progressiver Niereninsuffizienz. L-Arginin ist eine semi-essentielle Aminosäure und über seinen endogenen Metaboliten Stickoxid (NO) in komplexer Weise mit renaler Matrixvermehrung verbunden. In dieser Arbeit wurde untersucht, wie sich die Gabe von L-Arginin auf die Matrixexpansion bei experimenteller, immun-vermittelter Nierenerkrankung auswirkt. Im Modell der akuten Anti-Thy1-Glomerulonephritis der Ratte und der chronischen Lupusnephritis der MRL/lpr-Maus wurde gezeigt, daß die Aktivierung des L-Arginin-NO-Stoffwechsels sowohl mit günstigen als auch mit ungünstigen Wirkungen auf die renale Matrixakkumulation verbunden ist. Diese "duale" Wirkung von L-Arginin ist im wesentlichen als Ausdruck der "ambivalenten" Wirkung von NO zu deuten. Antifibrotische Wirkungen von L-Arginin stehen in enger Verbindung mit einer gesteigerten endothelialen NO-Synthese. Neben renaler Blutdrucksenkung vermittelt die endotheliale NO-Synthase auch parakrin wichtige antifibrotische Effekte. Profibrotische Wirkungen von L-Arginin stehen in engem Zusammenhang mit einer gesteigerten NO-Synthese durch induzierbare, destruktive NO-Synthasen. Folgen sind verstärkte Organschädigung und beschleunigte Progression von renaler Funktionseinschränkung.Ongoing expansion of extracellular matrix proteins is a hallmark of progressive chronic renal insufficiency. L-Arginine is a semi-essential amino acid and alters renal matrix accumulation via its endogenous metabolite nitric oxide (NO) in a complex manner. The present study analyzed how administration of L-arginine affects renal matrix accumulation in experimental immune-mediated disease. In acute anti-Thy1 glomerulonephritis of the rat and chronic lupus nephritis of MRL/lpr-mice, activation of the L-arginine-NO-pathway was related to both beneficial and detrimental actions on renal matrix accumulation. This "dual" effect of L-arginine administration essentially reflects the "ambivalent" nature of NO. Antifibrotic actions of L-arginine are associated with increased endothelial NO synthesis. In addition to lowering glomerular blood pressure, endothelial NO production mediates important paracrine antifibrotic actions. Profibrotic effects of L-arginine are related to increased NO production by inducible, destructive NO synthases, resulting in increased organ damage and accelerated progression of chronic kidney insufficiency

Evaluation of the free, open source software WordPress as electronic portfolio system in undergraduate medical education

Background Electronic portfolios (ePortfolios) are used to document and support learning activities. E-portfolios with mobile capabilities allow even more flexibility. However, the development or acquisition of ePortfolio software is often costly, and at the same time, commercially available systems may not sufficiently fit the institution’s needs. The aim of this study was to design and evaluate an ePortfolio system with mobile capabilities using a commercially free and open source software solution. Methods We created an online ePortfolio environment using the blogging software WordPress based on reported capability features of such software by a qualitative weight and sum method. Technical implementation and usability were evaluated by 25 medical students during their clinical training by quantitative and qualitative means using online questionnaires and focus groups. Results The WordPress ePortfolio environment allowed students a broad spectrum of activities – often documented via mobile devices – like collection of multimedia evidences, posting reflections, messaging, web publishing, ePortfolio searches, collaborative learning, knowledge management in a content management system including a wiki and RSS feeds, and the use of aid tools for studying. The students’ experience with WordPress revealed a few technical problems, and this report provides workarounds. The WordPress ePortfolio was rated positively by the students as a content management system (67 % of the students), for exchange with other students (74 %), as a note pad for reflections (53 %) and for its potential as an information source for assessment (48 %) and exchange with a mentor (68 %). On the negative side, 74 % of the students in this pilot study did not find it easy to get started with the system, and 63 % rated the ePortfolio as not being user-friendly. Qualitative analysis indicated a need for more introductory information and training. Conclusions It is possible to build an advanced ePortfolio system with mobile capabilities with the free and open source software WordPress. This allows institutions without proprietary software to build a sophisticated ePortfolio system adapted to their needs with relatively few resources. The implementation of WordPress should be accompanied by introductory courses in the use of the software and its apps in order to facilitate its usability

Tandem antifibrotic actions of L-arginine supplementation and low protein diet during the repair phase of experimental glomerulonephritis

Tandem antifibrotic actions of L-arginine supplementation and low protein diet during the repair phase of experimental glomerulonephritis.BackgroundBased upon the central role transforming growth factor-beta (TGF-β) overexpression appears to play in renal fibrotic diseases, we have recently advocated reduction of TGF-β as a therapeutic target. As part of efforts to determine the strength of this approach, we have undertaken studies to quantitate the effects of currently used and promising therapies in terms of their potential to reduce markers of disease in anti-thymocyte-serum (ATS)-glomerulonephritis in the rat. Here we assess the therapeutic effect of L-arginine supplementation, which has been shown to reduce fibrosis in a number of hypertensive models, given alone or in combination with low protein diet and started 24 hours after disease induction.MethodsGlomerulonephritis was induced by intravenous injection of OX-7 monoclonal antibody into 200g Sprague-Dawley rats. Twenty-four hours later animals were placed in groups that were either untreated, treated with 1% L-arginine in drinking water or 6% protein diets or both. On the fifth day of disease 24-hour urine specimens were collected and systemic blood pressure was measured. On the sixth day rats were anesthetized. Kidneys were perfused, tissue was taken for PAS staining and glomeruli were isolated. Aliquots of glomeruli were used for RNA preparation and for culture to determine 72-hour production of TGF-β, fibronectin and plasminogen activator-type 1 (PAI-1), which were assayed by ELISA on culture supernatants. Measures of nitrate and nitrite (NOx) production included plasma NOx, urinary NOx and glomerular production of NOx in culture.ResultsAll disease measures except proteinuria and including matrix accumulation, TGF-β, fibronectin and PAI-1 production and mRNA expression for TGF-β, fibronectin and PAI-1 were significantly and similarly reduced by about 50% in groups treated with L-arginine or with low protein diet. Proteinuria was reduced in low protein treated but not in L-arginine supplemented rats. Neither systemic blood pressure nor measures of NO synthesis showed differences between groups that could be attributed to L-arginine supplementation. In contrast, disease-related increases in glomerular production of NOx were markedly reduced by low protein. Combined therapy resulted in small, but statistically significant decreases in most measures of disease.ConclusionsL-arginine supplementation reduces fibrotic disease in ATS-induced glomerulonephritis if started after disease induction. The absence of evidence for increased NO production related to L-arginine supplementation suggests that L-arginine is acting here through different pathways from those demonstrated in hypertensive models of disease. The data support the ideas that TGF-β reduction is a valid therapeutic target and that quantitation of TGF-β reduction is a useful approach for comparing antifibrotic drug candidates

What can we expect from medical graduates? Empirical survey on the performance of Core EPAs in the first days of residency

Background: Core Entrustable Professional Activities (EPAs) have been defined to specify the performance expectations for entering residents worldwide. The content of these EPAs was elaborated and validated primarily via medical expert consent approaches. The present study aims to collect empirical information on the actual task performance and supervision level of entering residents as a complementary methodological approach to enhance the content validity of a set of institutional EPAs. Methods: In the summers of 2017 and 2018, Charité medical graduates (n = 720) received a post-graduation survey by mail. The questionnaire covered the performance of Core EPAs, Core procedures and more advanced EPAs. Graduates were asked how frequently they had performed the respective EPAs since the start of residency and under what level of supervision. We expected the large majority of graduates (> 75%) to have performed the Core EPAs and procedures under at least indirect supervision. Results: In total, 215 graduates (30%) returned the questionnaire, and 131 (18%) surveys could be included in the data analysis. The majority of participants were female (63%) and worked in hospitals (50%) or in university medical centres (30%) across various medical disciplines. Among the Core EPAs, 10 out of 11 tasks had been performed by more than 75% of graduates since the start of residency, 9 under indirect supervision. Regarding the Core procedures, only 3 out of 13 procedures had been performed by the large majority of graduates under indirect supervision, and 10 procedures had not been carried out by at least one-third of participants. Among the 5 advanced EPAs, none of 5 had been performed by more than 75% of the participants since the start of residency, and 4 had been carried out by 50% under indirect supervision. Conclusions: The results of this study largely and complementarily confirm the validity of the defined Core EPAs representing realistic expectations for entry into residence at our institution. The low actual performance rate of Core procedures serves to stimulate an institutional discussion on their adjustment to better match the workplace reality

How do medical students learn conceptual knowledge? High-, moderate- and low-utility learning techniques and perceived learning difficulties

Background: Acquiring medical knowledge is a key competency for medical students and a lifelong requirement for physicians. Learning techniques can improve academic success and help students cope with stressors. To support students' learning process medical faculties should know about learning techniques. The purpose of this study is to analyse the preferred learning techniques of female and male as well as junior and senior medical students and how these learning techniques are related to perceived learning difficulties. Methods: In 2019, we conducted an online survey with students of the undergraduate, competency-based curriculum of medicine at Charite - Universitatsmedizin Berlin. We chose ten learning techniques of high, moderate and low utility according to Dunlosky et al. (2013) and we asked medical students to rate their preferred usage of those techniques using a 5-point Likert scale. We applied t-tests to show differences in usage between female and male as well as junior and senior learners. Additionally, we conducted a multiple regression analysis to explore the predictive power of learning techniques regarding perceived difficulties. Results: A total of 730 medical students (488 women, 242 men, M-age = 24.85, SD = 4.49) use three techniques the most: 'highlighting' (low utility), 'self-explanation' (moderate utility) and 'practice testing' (high utility). Female students showed a significantly higher usage of low-utility learning techniques (t(404.24) = -7.13, p < .001) and a higher usage of high-utility learning techniques (t(728) = -2.50, p < .05) than male students (M = 3.55, SD = .95). Compared to junior students (second to sixth semester; M = 3.65, SD = .71), senior students (seventh semester to final clerkship year; M = 3.52, SD = .73) showed a lower use of low-utility learning techniques (t(603) = 2.15, p < .05). Usage of low-utility techniques is related to more difficulties (beta = .08, t(724) = 2.13, p < .05). Usage of moderate-utility techniques is related to less learning difficulties (beta = -.13, t(599) = -3.21, p < .01). Conclusions: Students use a wide range of low-, moderate- and high-utility learning techniques. The use of learning techniques has an influence on the difficulties perceived by students. Therefore, they could benefit from knowing about and using high-utility learning techniques to facilitate their learning. Faculties should inform their students about effective learning and introduce them to useful learning techniques