Guidelines: The do's, don'ts and don't knows of direct observation of clinical skills in medical education.

IntroductionDirect observation of clinical skills is a key assessment strategy in competency-based medical education. The guidelines presented in this paper synthesize the literature on direct observation of clinical skills. The goal is to provide a practical list of Do's, Don'ts and Don't Knows about direct observation for supervisors who teach learners in the clinical setting and for educational leaders who are responsible for clinical training programs.MethodsWe built consensus through an iterative approach in which each author, based on their medical education and research knowledge and expertise, independently developed a list of Do's, Don'ts, and Don't Knows about direct observation of clinical skills. Lists were compiled, discussed and revised. We then sought and compiled evidence to support each guideline and determine the strength of each guideline.ResultsA final set of 33 Do's, Don'ts and Don't Knows is presented along with a summary of evidence for each guideline. Guidelines focus on two groups: individual supervisors and the educational leaders responsible for clinical training programs. Guidelines address recommendations for how to focus direct observation, select an assessment tool, promote high quality assessments, conduct rater training, and create a learning culture conducive to direct observation.ConclusionsHigh frequency, high quality direct observation of clinical skills can be challenging. These guidelines offer important evidence-based Do's and Don'ts that can help improve the frequency and quality of direct observation. Improving direct observation requires focus not just on individual supervisors and their learners, but also on the organizations and cultures in which they work and train. Additional research to address the Don't Knows can help educators realize the full potential of direct observation in competency-based education

Report on an experiment in five-day weather forecasting

The following report is presented as a statement of progress made at the Massachusetts Institute of Technology (M.I.T.) in the investigation into the possibility of extending the range of reliable weather forecasts. This project has been supported at M.I.T. and other private institutions by Bankhead-Jones appropriations since September, 1937. This report is concerned only with the work completed or in progress at M.I.T. The complementary program now in progress at the Weather Bureau in Washington is referred to only in so far as it has contributed directly to these investigations. Furthermore, the following report refers only to the last two years of the M.I.T. project. The first year of the three-year project was given over principally to the study of the results obtained by long range forecast methods already in use, and to the establishment of a northern hemisphere synoptic weather map procedure as a necessary precedent to the preparation of weekly forecasts on a synoptic basis. The results of the M.I.T. study of certain long range forecast methods already in practice are included in a general survey of such methods already published. The synoptic charts prepared at M.I.T. during that first year of the investigation are listed in an appendix to this report, together with those of the last two years. The preparation of weekly forecasts carried on during a part of that first year was so experimental in nature, and the procedure was so much changed the following year, that the results obtained were considered neither suffciently significant nor comparable enough with the later forecast results to merit any discussion. The present report is divided into three principal sections. Section I presents in condensed form our present conception of the essential nature of the general circulation, and discusses briefly the background of one or two of Professor Rossby's theoretical considerations concerning the general circulation which have found statistical and synoptic application in this investigation. Section II contains in brief form the results of synoptic and statistical checks of a large number of hypothetical relationships which might be assumed to hold in the earth's atmosphere. These include possible relationships in the large scale features of the general circulation, relationships between the general circulation and its different branches or centers of action, between the different branches or centers of action of the general circulation, between characteristics of the general circulation or its branches and anomalies of the meteorological elements in certain regions, between anomalies of the meteorological elements in one region and those in another region, and even between solar activity (sunspots) and characteristics of the general circulation or anomalies of the meteorological elements. The aim was to investigate possible interrelationships of all kinds, either with or without lag, in order to detect as many interaction principles or points as possible in the earth's atmosphere, whether they had direct or only the most indirect bearing on the forecast problem. The relationships investigated applied to daily, weekly, monthly, seasonal, or annual mean conditions. They were selected for investigation either from theoretical or practical considerations of the nature of the general circulation as outlined in Section I, or on the basis of popular beliefs which have long been current among meteorologists, or on the basis of direct observation of data which looked promising. The majority of these hypothetical relationships are found to be quite weak when subjected to rigid statistical checks, but all such results, whether positive or negative, are summarized in this report. Section III outlines the five-day forecast routine practice which has been carried on at M.I.T. during the greater part of the past two years on a weekly basis. It includes a statistical analysis of the verification results. In the conclusion are summarized the results of the investigation which thus far appear significant enough to justify their consideration in five-day or longer range forecasts. Suggestions are offered as to further steps which might profitably be taken if the investigation is to be continued. Finally there is an appendix in which are listed all the daily synoptic maps and mean charts and diagrams of surface and upper air data which have been plotted and analyzed at M.I.T. in connection with this project during the past three years. The importance of such a list is apparent when it is realized that inevitably in an investigation of this kind much the greater part of the time and effort expended is consumed in the routine or semiroutine duties involved in the preparation of such charts

Relation between variations in the intensity of the zonal circulation of the atmosphere and the displacements of the permanent centers of action atmosphere and the displacements of the permanent centers of action

This paper attempts to interpret, from a single point of view, several at first sight independent phenomena brought into focus through the synoptic investigations carried on at the Massachusetts Institute of Technology during the last few years…

Doctor@Home: Through a Telemedicine Co-production and Co-learning Journey

Telemedicine and remote visits are becoming more and more popular in several medical disciplines, including oncology. The Covid-19 pandemic has enhanced the need to continue to meet patients’ ambulatory care necessities ensuring social distancing and limiting the access to clinical facilities. The National Cancer Institute of Aviano, Italy, has recently launched a program called “Doctor @ Home” (D@H). The pillars of the program are the co-production of the oncological care and the co-learning approach, which sees the clinical staff “hand in hand” with patients to maximize the outcome of the care, trying to take advantage of the new tools offered by modern technologies

Structure and Mobility of Lactose in Lactose/Sodium Montmorillonite Nanocomposites

This study aims at investigating the molecular level organization and molecular mobility in montmorillonite nanocomposites with the uncharged organic low-molecular-weight compound lactose commonly used in pharmaceutical drug delivery, food technology, and flavoring. Nanocomposites were prepared under slow and fast drying conditions, attained by drying at ambient conditions and by spray-drying, respectively. A detailed structural investigation was performed with modulated differential scanning calorimetry, powder X-ray diffraction, solid-state nuclear magnetic resonance, scanning electron microscopy, microcalorimetry, and molecular dynamic simulations. The lactose was intercalated in the sodium montmorillonite interlayer space regardless of the clay content, drying rate, or humidity exposure. Although, the spray-drying resulted in higher proportion of intercalated lactose compared with the drying under ambient conditions, non-intercalated lactose was present at 20 wt% lactose content. This indicates limitations in maximum load capacity of nonionic organic substances into the montmorillonite interlayer space. Furthermore, a fraction of the intercalated lactose in the co-spray-dried nanocomposites diffused out from the clay interlayer space upon humidity exposure. Also, the lactose in the nanocomposites demonstrated higher molecular mobility than that of neat amorphous lactose. This study provides a foundation for understanding functional properties of nanocomposites, such as loading capacity and physical stability

'Correction:'Peer chart audits: A tool to meet Accreditation Council on Graduate Medical Education (ACGME) competency in practice-based learning and improvement

<p>Abstract</p> <p>Background</p> <p>The Accreditation Council on Graduate Medical Education (ACGME) supports chart audit as a method to track competency in Practice-Based Learning and Improvement. We examined whether peer chart audits performed by internal medicine residents were associated with improved documentation of foot care in patients with diabetes mellitus.</p> <p>Methods</p> <p>A retrospective electronic chart review was performed on 347 patients with diabetes mellitus cared for by internal medicine residents in a university-based continuity clinic from May 2003 to September 2004. Residents abstracted information pertaining to documentation of foot examinations (neurological, vascular, and skin) from the charts of patients followed by their physician peers. No formal feedback or education was provided.</p> <p>Results</p> <p>Significant improvement in the documentation of foot exams was observed over the course of the study. The percentage of patients receiving neurological, vascular, and skin exams increased by 20% (from 13% to 33%) (p = 0.001), 26% (from 45% to 71%) (p < 0.001), and 18% (51%–72%) (p = 0.005), respectively. Similarly, the proportion of patients receiving a well-documented exam which includes all three components – neurological, vascular and skin foot exam – increased over time (6% to 24%, p < 0.001).</p> <p>Conclusion</p> <p>Peer chart audits performed by residents in the absence of formal feedback were associated with improved documentation of the foot exam in patients with diabetes mellitus. Although this study suggests that peer chart audits may be an effective tool to improve practice-based learning and documentation of foot care in diabetic patients, evaluating the actual performance of clinical care was beyond the scope of this study and would be better addressed by a randomized controlled trial.</p

Associations between subspecialty fellowship interest and knowledge of internal medicine: A hypothesis-generating study of internal medicine residents

<p>Abstract</p> <p>Background</p> <p>Little is known about whether and how medical knowledge relates to interest in subspecialty fellowship training. The purpose of this study was to examine the relationships between residents' interest in subspecialty fellowship training and their knowledge of internal medicine (IM).</p> <p>Methods</p> <p>A questionnaire was emailed to 48 categorical postgraduate-year (PGY) two and three residents at a New York university-affiliated IM residency program in 2007 using the Survey Monkey online survey instrument. Overall and content area-specific percentile scores from the IM in-training examination (IM-ITE) for the same year was used to determine objective knowledge.</p> <p>Results</p> <p>Forty-five of 48 residents (response rate was 93.8%) completed the survey. Twenty-two (49%) were PG2 residents and 23(51%) were PGY3 residents. Sixty percent of respondents were male. Six (13%) residents were graduates of U.S. medical schools. Eight (18%) reported formal clinical training prior to starting internal medicine residency in the U.S. Of this latter group, 6 (75%) had training in IM and 6 (75) % reported a training length of 3 years or less. Thirty-seven of 45 (82%) residents had a subspecialty fellowship interest. Residents with a fellowship interest had a greater mean overall objective knowledge percentile score (56.44 vs. 31.67; p = 0.04) as well as greater mean percentile scores in all content areas of IM. The adjusted mean difference was statistically significant (p < 0.02) across three content areas.</p> <p>Conclusions</p> <p>More than half of surveyed residents indicated interest in pursuing a subspecialty fellowship. Fellowship interest appears positively associated with general medical knowledge in this study population. Further work is needed to explore motivation and study patterns among internal medicine residents.</p

Inotropic Effects of Prostacyclins on the Right Ventricle Are Abolished in Isolated Rat Hearts With Right-Ventricular Hypertrophy and Failure

BACKGROUND: Prostacyclin mimetics are vasodilatory agents used in the treatment of pulmonary arterial hypertension. The direct effects of prostanoids on right-ventricular (RV) function are unknown. We aimed to investigate the direct effects of prostacyclin mimetics on RV function in hearts with and without RV hypertrophy and failure. METHODS: Wistar rats were subjected to pulmonary trunk banding to induce compensated RV hypertrophy (n = 32) or manifest RV failure (n = 32). Rats without banding served as healthy controls (n = 30). The hearts were excised and perfused in a Langendorff system and subjected to iloprost, treprostinil, epoprostenol, or MRE-269 in increasing concentrations. The effect on RV function was evaluated using a balloon-tipped catheter inserted into the right ventricle. RESULTS: In control hearts, iloprost, treprostinil, and MRE-269 improved RV function. The effect was, however, absent in hearts with RV hypertrophy and failure. Treprostinil and MRE-269 even impaired RV function in hearts with manifest RV failure. CONCLUSIONS: Iloprost, treprostinil, and MRE-269 improved RV function in the healthy rat heart. RV hypertrophy abolished the positive inotropic effect, and in the failing right ventricle, MRE-269 and treprostinil impaired RV function. This may be related to changes in prostanoid receptor expression and reduced coronary flow reserve in the hypertrophic and failing right ventricle