Chia-Chang Huang

Assessment of first-year post-graduate residents: Usefulness of multiple tools

Background: Objective Structural Clinical Examination (OSCE) usually needs a large number of stations with long test time, which usually exceeds the resources available in a medical center. We aimed to determine the reliability of a combination of Direct Observation of Procedural Skills (DOPS), Internal Medicine in‐Training Examination (IM‐ITE®) and OSCE, and to verify the correlation between the small‐scale OSCE+DOPS+IM‐ITE®‐composited scores and 360‐degree evaluation scores of first year post‐graduate (PGY1) residents. Methods: Between 2007 January to 2010 January, two hundred and nine internal medicine PGY1 residents completed DOPS, IM‐ITE® and small‐scale OSCE at our hospital. Faculty members completed 12‐item 360‐degree evaluation for each of the PGY1 residents regularly. Results: The small‐scale OSCE scores correlated well with the 360‐degree evaluation scores (r = 0.37, p < 0.021). Interestingly, the addition of DOPS scores to small‐scale OSCE scores [small‐scale OSCE+DOPS‐composited scores] increased its correlation with 360‐degree evaluation scores of PGY1 residents (r = 0.72, p < 0.036). Further, combination of IM‐ITE® score with small‐scale OSCE+DOPS scores [small‐scale OSCE+DOPS+IM‐ITE®‐composited scores] markedly enhanced their correlation with 360‐degree evaluation scores (r = 0.85, p < 0.016). Conclusion: The strong correlations between 360‐degree evaluation and small‐scale OSCE+DOPS+IM‐ITE®‐composited scores suggested that both methods were measuring the same quality. Our results showed that the small‐scale OSCE, when associated with both the DOPS and IM‐ITE®, could be an important assessment method for PGY1 residents.

Short‐term use of glucocorticoids and risk of peptic ulcer bleeding: a nationwide population‐based case‐crossover study

Controversy exists regarding glucocorticoids therapy and the risk of peptic ulcer bleeding (PUB).

A core competence-based objective structured clinical examination (OSCE) in evaluation of clinical performance of postgraduate year-1 (PGY1) residents

Background: Clinical competency certifications are important parts of internal medicine residency training. This study aims to evaluate a composite objective structured clinical examination (OSCE) that assesses postgraduate year‐1 (PGY1) residents’ acquisition of the six core competencies defined by the Accreditation council for Graduate Medical Education (ACGME). Methods: Six‐core‐competency‐based OSCE was used as examination of the clinical performance of 192 PGY1 residents during their 3‐month internal medicine training between 2007 January and 2009 December. For each year, the reliability of the entire examination was calculated with Cronbach’s alpha. Results: The reliability of six‐core‐competency‐based OSCE was acceptable, ranging from 0.69 to 0.87 between 2007 and 2009. In comparison with baseline scores, the summary scores and core‐competency subscores all showed significant increase after PGY1 residents finished their 3‐month internal medicine training program. Conclusion: By using a structured development process, the authors were able to create reliable evaluation items for determining PGY1 residents’ acquisition of the ACGME core competencies.

Serum pentraxin-3 and tumor necrosis factor-like weak inducer of apoptosis (TWEAK) predict severity of infections in acute decompensated cirrhotic patients

BACKGROUND Pentraxin-3 (PTX3) and soluble tumor necrosis factor (TNF)-like weak inducer of apoptosis (sTWEAK) are new candidate prognostic markers for comorbidities and mortality in various inflammatory diseases. Acute decompensation of cirrhosis is characterized by acute exacerbation of chronic systemic inflammation. Recently, increased circulating PTX3 levels have been reported in nonalcoholic steatohepatitis patients and positively correlated with disease severity. This study aims to explore serum PTX3/sTWEAK levels and their relationship with clinical outcomes in cirrhotic patients with acute decompensation. METHODS We analyzed serum PTX3/sTWEAK levels in relation to inhospital and 3-month new clinical events and survivals in cirrhotic patients with acute decompensation. RESULTS During admission, serum PTX3/sTWEAK levels were significantly higher in acute decompensated cirrhotic patients than controls and positively correlated with protein-energy wasting (PEW), new infections, long hospital stays, high medical costs, and high mortality. During a 3-month follow-up, acute decompensated cirrhotic patients with high serum PTX3/sTWEAK levels had more episodes of unplanned readmission and high 3-month mortality. On multivariate analysis, high PTX3/sTWEAK levels and PEW were independent risk factors for high mortality. CONCLUSION High serum PTX3/sTWEAK levels and PEW are common in cirrhotic patients with acute decompensation. As compared with low serum PTX3 and sTWEAK cases, cirrhotic patients with high serum PTX3/sTWEAK levels a have higher probability of new severe infections, severe sepsis, septic shock, type 1 hepatorenal syndrome, in-hospital, and 3-month follow-up mortalities. Therefore, high serum PTX3/sTWEAK levels on hospital admission predict disease severity and case fatality in cirrhotic patients with acute decompensation.

The influence of gender on the communication skills assessment of medical students

BACKGROUND Opinions on the interaction between the genders of standardized patients and examinees are controversial. Our study sought to determine the influence of gender on communication skills assessment in Eastern country. METHODS We recruited year 5 medical students from a medical college in Taiwan. They were assigned to obtain informed consent from either male or female age-matched standardized patients. Their performance was rated by standardized checklist rating scores and global rating scores. Either male or female examiners rated their performance. RESULTS A total of 253 medical students (166 male students and 87 female students) were recruited. The checklist rating scores for students interacting with male standardized patients were significantly lower than the scores for interactions with female standardized patients (male examiners, P=0.006; female examiners, P=0.001). For male students, the checklist rating scores were significantly lower for male standardized patients than for female standardized patients (male examiners, P=0.006; female examiners, P=0.008). For male standardized patients, male students had significantly lower checklist rating scores than female students when rated by male examiners (P=0.044). The global rating scores were similar except when female students interacted with male and female SPs and when rated by female examiners (P=0.004). CONCLUSION The gender of standardized patients influences communication skills assessment. In terms of checklist rating scores, female standardized patients seem preferable to minimize potential gender effects. In the best interest of students, global rating score may be preferable to checklist rating score, especially for male examinees.

Validation of the behavior and concept based assessment of professionalism competence in postgraduate first-year residents

Background: The evaluation of professional behaviors and concepts of postgraduate first‐year (PGY1) residents has been identified as an area for development. This study examined the efficiency of the professionalism‐assessing objective structured clinical examination (OSCE), 360° evaluation, and mini‐Clinical Examination Exercise scores (mini‐CEX; p‐OSCE, p‐360° evaluation, and p‐mini‐CEX scores). Methods: Between January 2009 and January 2012, 189 PGY1 residents were evaluated for behavior‐ and concept‐based professionalism competence based on the above three methods using two checklists unique to each case. Data were analyzed for reliability, inter‐rater agreement, interval changes, and gender‐related difference for each method. Results: The test reliabilities of p‐OSCE, p‐360° evaluation, and p‐mini‐CEX were acceptable. Further, the reliability of concept and combined p‐OSCE was higher than that of behavior p‐OSCE. In addition, the concept OSCE p‐scores and behavior 360° evaluation p‐scores were significantly improved after 6 months of training. The inter‐rater agreements were relatively good in p‐OSCE and p‐360° evaluation. Interestingly, male PGY1 residents had higher behavior 360° evaluation p‐scores from nurses than those of females, whereas female PGY1 residents had higher behavior 360° evaluation p‐scores from patients than those of males. Behavior and concept OSCE p‐scores were positively correlated with behavior 360° evaluation p‐scores. In comparison with p‐360° evaluation, the combination of p‐360° evaluation + OSCE + mini‐CEX significantly increases their reliabilities. Conclusion: The current study suggests that the p‐OSCE, p‐360° evaluation, and p‐mini‐CEX are feasible methods for evaluating professionalism in clinical training of PGY1 residents. Combination of the above three evaluations, participation, and support from multiple constituencies and multiple representatives provides good reliability and adds credibility in the assessment of professionalism competence.

Simulation-based inter-professional education to improve attitudes towards collaborative practice: a prospective comparative pilot study in a Chinese medical centre

Objectives Inter-professional education (IPE) builds inter-professional collaboration (IPC) attitude/skills of health professionals. This interventional IPE programme evaluates whether benchmarking sharing can successfully cultivate seed instructors responsible for improving their team members’ IPC attitudes. Design Prospective, pre-post comparative cross-sectional pilot study. Setting/participants Thirty four physicians, 30 nurses and 24 pharmacists, who volunteered to be trained as seed instructors participated in 3.5-hour preparation and 3.5-hour simulation courses. Then, participants (n=88) drew lots to decide 44 presenters, half of each profession, who needed to prepare IPC benchmarking and formed Group 1. The remaining participants formed Group 2 (regular). Facilitators rated the Group 1 participants’ degree of appropriate transfer and sustainable practice of the learnt IPC skills in the workplace according to successful IPC examples in their benchmarking sharing. Results For the three professions, improvement in IPC attitude was identified by sequential increase in the post-course (second month, T2) and end-of-study (third month, T3) Interdisciplinary Education Perception Scale (IEPS) and Attitudes Towards Healthcare Teams Scale (ATHCTS) scores, compared with pre-course (first month, T1) scores. By IEPS and ATHCTS-based assessment, the degree of sequential improvements in IPC attitude was found to be higher among nurses and pharmacists than in physicians. In benchmarking sharing, the facilitators’ agreement about the degree of participants’appropriate transfer and sustainable practice learnt ‘communication and teamwork’ skills in the workplace were significantly higher among pharmacists and nurses than among physicians. The post-intervention random sampling survey (sixth month, Tpost) found that the IPC attitude of the three professions improved after on-site IPC skill promotion by new programme-trained seed instructors within teams. Conclusions Addition of benchmark sharing to a diamond-based IPE simulation programme enhances participants’ IPC attitudes, self-reflection, workplace transfer and practice of the learnt skills. Furthermore, IPC promotion within teams by newly trained seed instructors improved the IPC attitudes across all three professions.

Chronic calcitriol supplementation improves the inflammatory profiles of circulating monocytes and the associated intestinal/adipose tissue alteration in a diet-induced steatohepatitis rat model

Vitamin D deficiency and up-regulated TNFα-related signals are reported to be involved in abnormalities including intestinal hyper-permeability, bacterial translocation, systemic/portal endotoxemia, intestinal/adipose tissue/hepatic inflammation, and hepatic steatosis in nonalcoholic steatohepatitis (NASH). This study aims to explore the molecular mechanisms and effects of chronic calcitriol [1,25-(OH)2D3, hormonal form of vitamin D] on gut-adipose tissue-liver axis abnormalities using a high-fat diet (HFD)-fed rat model of NASH. In HFD-fed obese rats on a 10-week calcitriol (0.3 μg/kg/TIW) or vehicle treatment (NASH-vit. D and NASH-V rats) reigme, various in vivo and in vitro experiments were undertaken. Through anti-TNFα-TNFR1-NFκB signaling effects, chronic calcitriol treatment significantly restored plasma calcitriol levels and significantly improved vitamin D receptor (VDR) expression in monocytes and the small intestine of NASH-vit. D rats. Significantly, plasma and portal endotoxin/TNFα levels, bacterial translocation to mesenteric lymph nodes, plasma DX-4000-FITC, fecal albumin-assessed intestinal hyper-permeability, over-expression of TNFα-related immune profiles in monocytes, inflammation of intestinal/mesenteric adipose tissue (MAT)/liver and hepatic steatosis were improved by chronic calcitriol treatment of NASH rats. Additionally, in vitro experiments with acute calcitriol co-incubation reversed NASH-V rat monocyte supernatant/TNFα-induced monolayer barrier dysfunction in caco-2 cells, cytokine release from MAT-derived adipocytes, and triglyceride synthesis by lean-V rat hepatocytes. Using in vivo and in vitro experiments, our study reported calcitriol signaling in the gut as well as in adipose tissue. Meanwhile, our study suggests that restoration of systemic and intestinal vitamin D deficiency using by chronic vitamin D treatment effectively reduces TNFα-mediated immunological abnormalities associated with the gut-adipose tissue-liver axis and hepatic steatosis in NASH rats.

Mixed simulation course increases participants' positive stress coping abilities

Background: Lack of health professional awareness of interprofessional collaborative practice (IPCP) often results in stress and conflicts between team members in the medical system. Our study aimed to compare the effectiveness of mixed simulation‐interprofessional education (IPE) courses to enhance coping strategies for IPCP‐associated stress. Methods: Participants (n = 54) from the disciplines of physicians (n = 12), nurses (n = 28) and pharmacists (n = 14) were enrolled. Over the course of the study period, all participants were asked to complete pre‐course (T1), post‐course (T2) and end‐of‐study (T3) questionnaires for self‐assessment of perceived stress scale (PSS), stress coping preference scale (SCPS), and IPCP proficiency. Results: Basically, physicians felt less IPCP‐associated stress than did nurses and pharmacists. For physicians, nurses and pharmacists, the mean post‐course (T2) PSS scores were significantly lower than pre‐course (T1) PSS scores, which indicated decreased IPCP‐associated stress after mixed simulation‐IPE courses. In comparison with physicians, the greater difference (T2–T1 scores) in the PSS and positive coping SCPS subscales scores were noted among nurses and pharmacists. For nurses and pharmacists, the further improvements in stress coping abilities (PSS scale and positive SCPS subscale) were noted at the end‐of‐study self‐assessment by comparison of post‐course scores with end‐of‐study scores. For IPCP proficiency, all participants gave more positive responses to the specific questions in the end‐of‐study questionnaires. Conclusion: Our study supports the use of mixed simulation‐IPE courses as part of continuing education to enhance positive stress coping strategies.

Peer-assisted learning model enhances clinical clerk's procedural skills

Background: Failure to transfer procedural skills learned in a laboratory to the bedside is commonly due to a lack of peer support/stimulation. A digital platform (Facebook) allows new clinical clerks to share experiences and tips that help augment their procedural skills in a peer‐assisted learning/teaching method. This study aims to investigate the effectiveness of the innovation of using the digital platform to support the transfer of laboratory‐trained procedural skills in the clinical units. Methods: Volunteer clinical clerks (n = 44) were enrolled into the peer‐assisted learning (PAL) group, which was characterized by the peer‐assisted learning of procedural skills during their final 3‐month clinical clerkship block. Other clerks (n = 51) did not join the procedural skills‐specific Facebook group and served as the self‐directed learning regular group. The participants in both the PAL and regular groups completed pre‐ and post‐intervention self‐assessments for general self‐assessed efficiency ratings (GSER) and skills specific self‐assessed efficiency ratings (SSSER) for performing vein puncture, intravenous (IV) catheter and nasogastric (NG) tube insertion. Finally, all clerks received the post‐intervention 3‐station Objective Structured Clinical Skills Examination (OSCE) to test their proficiency for the abovementioned three procedural skills. Results: Higher cumulative numbers of vein punctures, IV catheter insertions and NG tube insertions at the bedside were carried out by the PAL group than the regular group. A greater improvement in GSERs and SSSERs for medical procedures was found in the PAL group than in the regular group. The PAL group obtained higher procedural skills scores in the post‐intervention OSCEs than the regular group. Conclusion: Our study suggested that the implementation of a procedural skill‐specific digital platform effectively helps clerks to transfer laboratory‐trained procedural skills into the clinical units. In comparison with the regular self‐directed learning group, the peer‐assisted learning characteristics of Facebook give additional benefits to the PAL group by enhancing their procedural skills.