Cristian A Herrera

Measuring the educational environment in health professions studies: A systematic review

Background: One of the determinants of the medical students behaviour is the medical school learning environment. Aim: The aim of this research was to identify the instruments used to measure the educational environment in health professions education and to assess their validity and reliability. Methods: We performed an electronic search in the medical literature analysis and retrieval system online (MEDLINE) and Timelit (Topics in medical education) databases through to October 2008. The non-electronic search (hand searching) was conducted through reviewing the references of the retrieved studies and identifying the relevant ones. Two independent authors read, rated and selected studies for the review according to the pre-specified criteria. The inter-rater agreement was measured with Kappa coefficient. Results: Seventy-nine studies were included with the Kappa coefficient of 0.79, which demonstrated a reliable process, and 31 instruments were extracted. The Dundee Ready Education Environment Measure, Postgraduate Hospital Educational Environment Measure, Clinical Learning Environment and Supervision and Dental Student Learning Environment Survey are likely to be the most suitable instruments for undergraduate medicine, postgraduate medicine, nursing and dental education, respectively. Conclusions: As a valid and reliable instrument is available for each educational setting, a study to assess the educational environment should become a part of an institutions good educational practice. Further studies employing a wider range of databases with more elaborated search strategies will increase the comprehensiveness of the systematic review.

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US

Psychometric analyses and internal consistency of the PHEEM questionnaire to measure the clinical learning environment in the clerkship of a Medical School in Chile

6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Evaluación del ambiente educacional pre-clínico en seis Escuelas de Medicina en Chile

Background and aims: The Spanish version of the Postgraduate Hospital Educational Environment Measure (PHEEM) was evaluated in this study to determine its psychometric properties, validity and internal consistency to measure the clinical learning environment in the hospital setting of Pontificia Universidad Católica de Chile Medical Schools Internship. Methods: The 40-item PHEEM questionnaire was translated from English to Spanish and retranslated to English. Content validity was tested by a focus group and minor differences in meaning were adjusted. The PHEEM was administered to clerks in years 6 and 7. Construct validity was carried out using exploratory factor analysis followed by a Varimax rotation. Internal consistency was measured using Cronbachs α. Results: A total of 125 out of 220 students responded to the PHEEM. The overall response rate was 56.8% and compliances with each item ranged from 99.2% to 100%. Analyses indicate that five factors instrument accounting for 58% of the variance and internal consistency of the 40-item questionnaire is 0.955 (Cronbachs α). The 40-item questionnaire had a mean score of 98.21 ± 21.2 (maximum score of 160). Conclusions: The Spanish version of PHEEM is a multidimensional, valid and highly reliable instrument measuring the educational environment among undergraduate medical students working in hospital-based clerkships.

Development of ACLEEM questionnaire, an instrument measuring residents' educational environment in postgraduate ambulatory setting

BACKGROUND The Dundee Ready Education Environment Measure (DREEM) is the most valid and reliable instrument to measure the educational environment (EE) in undergraduate medical education. AIM To evaluate the EE perceived by undergraduate medical students in Chile, using a Spanish version of the DREEM questionnaire. MATERIAL AND METHODS The DREEM was applied during 2008 in third, fourth and fifth undergraduate years of six medical schools. The individual results were calculated and means of both global and individual domain scores of the DREEM were compared, by year, gender and between different Schools. RESULTS One thousand ninety two students (77% of the total universe of students), answered the questionnaire. The mean score of the six Schools was 113.9. The domains of Perception ofLearning and Social Self-Perception obtained the lower scores, with a global outcome indicating a more positive than negative EE. Two schools obtained mean scores of 128.32 and 126.87, that were significantly higher than the global scores obtained by other schools. No relevant differences by years or gender were observed. CONCLUSIONS There is a significant variability between the six schools evaluated and two of these obtained significantly better scores than the rest. The identified positive and negative areas will orient the actions to improve the EE for undergraduate medical students.

The power of integration: radiotherapy and global palliative care.

Background: Students’ perceptions of their educational environment (EE) have been studied in undergraduate and postgraduate curricula. Postgraduate EE has been measured in hospital settings. However, there are no instruments available to measure the EE in postgraduate ambulatory settings. Aim: The aim of this study was to develop the “Ambulatory Care Learning Education Environment Measure” (ACLEEM). Methods: A mixed methodology was used including three stages: (1) Grounded theory (focus groups); (2) Delphi technique to identify consensus; and (3) Pilot study. Results: Three quota samples of approximately 60 stakeholders were formed, one as Focus Groups and two as Delphi panels. Eight focus groups were carried out including 58 residents (Latin-American Spanish speakers). The results were analysed and 173 items were offered to a National Delphi panel (61 residents and teachers). They reduced in two rounds the number of important items to 54. The 54-item questionnaire was then piloted with 63 residents and refined to the final version of the ACLEEM with 50 items and three domains. Conclusions: The 50-item inventory is a valid instrument to measure the EE in postgraduate ambulatory setting in Chile. Large-scale administration of the ACLEEM questionnaire to evaluate its construct validity and reliability are the next steps to test the psychometric properties of the instrument.

Identificación de las necesidades de capacitación docente de los jefes de programa de especialización médica

Radiotherapy (RT) is a powerful tool for the palliation of the symptoms of advanced cancer, although access to it is limited or absent in many low- and middle-income countries (LMICs). There are multiple factors contributing to this, including assumptions about the economic feasibility of RT in LMICs, the logical challenges of building capacity to deliver it in those regions, and the lack of political support to drive change of this kind. It is encouraging that the problem of RT access has begun to be included in the global discourse on cancer control and that palliative care and RT have been incorporated into national cancer control plans in some LMICs. Further, RT twinning programs involving high- and low-resource settings have been established to improve knowledge transfer and exchange. However, without large-scale action, the consequences of limited access to RT in LMICs will become dire. The number of new cancer cases around the world is expected to double by 2030, with twice as many deaths occurring in LMICs as in high-income countries (HICs). A sustained and coordinated effort involving research, education, and advocacy is required to engage global institutions, universities, health care providers, policymakers, and private industry in the urgent need to build RT capacity and delivery in LMICs.

Evaluación del ambiente educacional en programas de especialización médica

BACKGROUND Training of postgraduate medical specialty program managers (PMSPM) is essential for the proper development of their programs. AIM To identify the main training needs of PMSPM at a medical school. MATERIAL AND METHODS A mixed-methodology approach was implemented including focus group/interviews and the administration of the Program Managers Training Needs Assessment Questionnaire (PROMANAQ) developed by an expert panel with 59 items (with two sections: relevance/performance-self-perception). Higher priority was assigned to items with high relevance and low performance. RESULTS Forty five PMSPM completed the PROMANAQ (81.8% response rate). Both sections of PROMANAQ were highly reliable (Cronbach alpha of 0.95/0.97 for relevance/performance-self-perception, respectively). The items with higher priority value were evaluation of clinical educators, evaluation of teaching programs and accreditation of programs. Ten PMSPM were included in the focus group (18.2% of the universe). The findings of the qualitative component were concordant with the areas explored in the questionnaire. CONCLUSIONS The PROMANAQ is valid and reliable to identify the training needs of PMSPM. The views of PMSPM must be taken into account for faculty development planning.BACKGROUND Training of postgraduate medical specialty program managers (PMSPM) is essential for the proper development of their programs. AIM To identify the main training needs of PMSPM at a medical school. MATERIAL AND METHODS A mixed-methodology approach was implemented including focus group/interviews and the administration of the Program Managers Training Needs Assessment Questionnaire (PROMANAQ) developed by an expert panel with 59 items (with two sections: relevance/performance-self-perception). Higher priority was assigned to items with high relevance and low performance. RESULTS Forty five PMSPM completed the PROMANAQ (81.8% response rate). Both sections of PROMANAQ were highly reliable (Cronbach alpha of 0.95/0.97 for relevance/performance-self-perception, respectively). The items with higher priority value were evaluation of clinical educators, evaluation of teaching programs and accreditation of programs. Ten PMSPM were included in the focus group (18.2% of the universe). The findings of the qualitative component were concordant with the areas explored in the questionnaire. CONCLUSIONS The PROMANAQ is valid and reliable to identify the training needs of PMSPM. The views of PMSPM must be taken into account for faculty development planning.

Advancing access and equity: the vision of a new generation in cancer control

BACKGROUND The Postgraduate Hospital Education Environment Measure (PHEEM) questionnaire, is a valid and reliable instrument to measure the educational environment (EE) in postgraduate medical education. AIM To evaluate the EE perceived by the residents of a postgraduate training program using the PHEEM. MATERIAL AND METHODS The PHEEM was applied in 2010-2011 in 35 specialty programs. We calculated their individual results and compared means of both global and individual domain scores of the PHEEM, by gender, university of origin and nationality. Cronbachs alpha coefficients and D study (Generalizability theory) were performed for reliability. RESULTS Three hundred eighteen residents were surveyed (75.7% of the total universe). The mean score of the PHEEM was 105.09 ± 22.46 (65.7% of the maximal score) which is considered a positive EE. The instrument is highly reliable (Cronbachs alpha = 0.934). The D study found that 15 subjects are required to obtain reliable results (G coefficient = 0.813). There were no significant differences between gender and university of origin. Foreigners evaluated better the EE than Chileans and racism was not perceived. The programs showed a safe physical environment and teachers with good clinical skills. The negative aspects perceived were a lack of information about working hours, insufficient academic counseling, and scanty time left for extracurricular activities. CONCLUSIONS This questionnaire allowed us to identify positive aspects of the EE, and areas to be improved in the specialty programs. The PHEEM is a useful instrument to evaluate the EE in Spanish-speaking participants of medical specialty programs.Background: The Postgraduate Hospital Education Environment Measure (PHEEM) questionnaire, is a valid and reliable instrument to measure the educational environment (EE) in postgraduate medical education. Aim: To evaluate the EE perceived by the residents of a postgraduate training program using the PHEEM. Material and Methods: The PHEEM was applied in 2010-2011 in 35 specialty programs. We calculated their individual results and compared means of both global and individual domain scores of the PHEEM, by gender, university of origin and nationality. Cronbachs alpha coefficients and D study (Generalizability theory) were performed for reliability. Results: Three hundred eighteen residents were surveyed (75.7% of the total universe). The mean score of the PHEEM was 105.09 ± 22.46 (65.7% of the maximal score) which is considered a positive EE. The instrument is highly reliable (Cronbachs alpha = 0.934). The D study found that 15 subjects are required to obtain reliable results (G coefficient = 0.813). There were no significant differences between gender and university of origin. Foreigners evaluated better the EE than Chileans and racism was not perceived. The programs showed a safe physical environment and teachers with good clinical skills. The negative aspects perceived were a lack of information about working hours, insufficient academic counseling, and scanty time left for extracurricular activities. Conclusions: This questionnaire allowed us to identify positive aspects of the EE, and areas to be improved in the specialty programs. The PHEEM is a useful instrument to evaluate the EE in Spanish-speaking participants of medical specialty programs.

Interventions for controlling emigration of health professionals from low and middle-income countries

172 www.thelancet.com/oncology Vol 18 February 2017 As the next generation of cancer advocates and leaders, we inherit a legacy that is in many ways, remarkable. The past few decades have seen rapid and unparalleled progress in cancer control. Investigative breakthroughs, such as those in cancer genomics and immunology, have transformed our understanding of the disease. New discoveries in cancer prevention have mitigated risk factors, and improvements in surgical techniques, radiotherapy technologies, and systemic agents have led to substantial improvements in cancer cure rates— an absolute survival increase of roughly 20% during the past three decades. This progress has been impressive, but its distribution has not been equitable. Signifi cant disparities in cancer outcomes persist between and within countries resulting in a so-called cancer divide, a deplorable situation compounded by the fact that the greatest burden of cancer aff ects low-and-middle-income countries (LMICs). It is the call of our generation to close this cancer divide, especially in view of the rapid acceleration of the global burden of cancer and its consequent strain on social, economic, and health systems. The challenges are many. Inadequate prioritisation of eff ective prevention strategies exacerbates the global burden. Early detection is complicated by limited primary care and pathology capacity; in many LMICs, even the most basic diagnostic and treatment services are inaccessible or unaff ordable. Supportive and palliative care is absent in most of the world, a startling inequity that permits the needless suff ering Advancing access and equity: the vision of a new generation in cancer control cost of signifi cant fi nancial strain, inadequate palliative care, and unmanaged existential suff ering, it would seem so. The question arises as to how physicians can better manage the care of patients with advanced cancer in an age of unlimited access to knowledge. It is crucial that from the very outset hope is balanced against realism. In this, physicians, patient advocates, the media, government agencies, and the pharmaceutical industry all have parts to play in the provision of honest, measured information for patients and their families. Realistically, we need to accept that many of our patients will seek a second opinion (if not more) online, and be prepared to engage with them in interpreting the results of their enquiries. And yes, we should celebrate the victories with our patients. But we should also temper their expectations. As we inform our patients that their time may be limited, we should ask—“Is there anything you want or need to do that you haven’t yet done? In order for me to best look after you, I need to know what matters to you.” Confronting yes, but it is questions such as these that can profoundly refocus the therapeutic relationship in a way that acknowledges not only the limits of our ability to defy death, but the intrinsic value of the life that has been lived. In the post-truth age our obligations as physicians remain the same. We should use information with precision and wisdom, much as a surgeon uses a scalpel. As we strive to provide compassionate care, it is up to us to ensure not only a steady hand, but that the knife is not wrested from our grasp.