Eugene C. Corbett

Sharpening the Eye of the OSCE with Critical Action Analysis

Purpose When interpreting performance scores on an objective structured clinical examination (OSCE), are all checklist items created equal? Although assigning priority through checklist item weighting is often used to emphasize the clinical importance of selected checklist items, the authors propose the use of critical action analysis as an additional method for analyzing and discriminating clinical performance in clinical skill assessment exercises. A critical action is defined as an OSCE checklist item whose performance is critical to ensure an optimal patient outcome and avoid medical error. In this study, the authors analyzed a set of clerkship OSCE performance outcome data and compared the results of critical action analysis versus traditional checklist item performance scores. Method OSCE performance scores of 398 third-year clerkship students from 2003 to 2006 at the University of Virginia School of Medicine were analyzed using descriptive statistics and a logistic regression model. Through a consensus process, 10 of 25 OSCE cases were identified as containing critical actions. Results Students who scored above the median correctly performed the critical actions more often than those scoring lower. However, for 9 of 10 cases, 6% to 46% of higher-scoring students failed to perform the critical action correctly. Conclusions Failure to address this skill assessment outcome is a missed opportunity to more fully understand and apply the results of such examinations to the clinical performance development of medical students. Including critical action analysis in OSCE data interpretation sharpens the eye of the OSCE and enhances its value in clinical skill assessment.

When should students learn essential physical examination skills? Views of internal medicine clerkship directors in North America.

Purpose To determine whether any consensus exists among internal medicine clerkship directors regarding when students should acquire proficiency in selected physical examination (PE) skills. Method In 2004, the annual survey of Clerkship Directors in Internal Medicine (CDIM) included a question about the timing of PE-skills proficiency. (CDIM members are from 123 U.S. and Canadian medical schools.) A total of 259 members (123 institutional and 136 individual members) were asked the following question about 39 common physical examination skills, selected using a consensus process among the authors and members of the CDIM Council: “When in the medical school curriculum should medical students acquire proficiency for the following skills?” Results There were 157 respondents, an overall response rate of 60%. There were 89 (72%) responding institutional members and 68 (50%) responding individual members. Respondents agreed that 31 (80%) of the skills should be learned by the end of the clerkship year. However, considerable variability existed regarding when in the curriculum those skills should be learned: for only 18 of 39 skills was there 80% agreement on skills-learning timing. CDIM members were divided on whether normal examination findings should be learned before or during the clerkships. Conclusions Variability existed among CDIM members regarding their expectations for the timing of student physical examination learning in the undergraduate medical curriculum. Creating a common vision among clerkship directors and faculty regarding what neophyte clinicians must learn to do and when they are expected to be able to do it will help to address the issue of physical examination proficiency standards of medical students.

Intensive insulin therapy improved glycemic control more than oral hypoglycemic agents in newly diagnosed type 2 diabetes

Question In patients with newly diagnosed type 2 diabetes mellitus, does intensive insulin therapy improve glycemic control and remission rates more than oral hypoglycemic agents (OHAs)? Methods Design Randomized controlled trial. Allocation Concealed. Blinding Unblinded.* Follow-up period 1 year. Setting 9 centers in China. Patients 410 patients who were 25 to 70 years of age, had newly diagnosed type 2 diabetes according to World Health Organization criteria (1999), had fasting plasma glucose levels between 7.0 mmol/L (126 mg/dL) and 16.7 mmol/L (300 mg/dL), and had not received antihyperglycemic therapy. Exclusion criteria were acute or severe diabetic complications, severe comorbid illness, positive test result for glutamic acid decarboxylase antibody, maturity-onset diabetes in youth, or mitochondria diabetes mellitus. 382 patients (mean age 51 y, mean body mass index 25 kg/m2) received interventions. Intervention Patients were allocated to intensive insulin therapy given as a continuous subcutaneous infusion (CSII) (n =137) or as multiple daily injections (MDII) (n =124), or to OHAs (n =121). The CSII group received human insulin with an insulin pump. The MDII group received premeal Novolin-R and human insulin NPH at bedtime. Initial insulin doses were 0.4 to 0.5 IU/kg. The OHA group received gliclazide, 80 mg twice daily (increased to maximum of 160 mg twice daily), if body mass index (BMI) was between 20 and 25 kg/m2, or metformin, 0.5 g twice daily (increased to maximum of 2.0 g/d), if BMI was between 25 and 35 kg/m2. Treatment was stopped after normoglycemia was maintained for 2 weeks; patients were then instructed to continue diet and physical exercise only. Outcomes Time to initial glycemic control and remission at 1 year among the 352 patients (64% men) who achieved initial glycemic control. Patient follow-up 81% completed the study. Main results Time to glycemic control was shorter in the CSII (4.0 d, P <0.0001) and MDII (5.6 d, P =0.01) groups than in the OHA (9.3 d) group. Remission rates at 1 year were higher in the intensive-insulin groups than in the OHA group (Table). Conclusion In patients with newly diagnosed type 2 diabetes mellitus, intensive insulin therapy reduced time to glycemic control and had a higher remission rate than oral hypoglycemic agents. Continuous subcutaneous insulin infusion (CSII) or multiple daily insulin injections (MDII) vs oral hypoglycemic agents (OHA) in newly diagnosed type 2 diabetes mellitus Outcome at 1 y Insulin form Insulin OHA RBI (95% CI) NNT (CI) Remission CSII 51% 27% 91% (35 to 178) 5 (3 to 9) MDII 45% 27% 68% (16 to 147) 6 (4 to 19) Abbreviations defined in glossary. RBI, NNT, and CI calculated from data in article. Commentary The onset of type 2 diabetes is slow, gradual, and fraught with pathologic consequences, often before hyperglycemia is discovered. Once hyperglycemia is diagnosed and if blood glucose levels are not dangerously elevated, clinicians begin care that includes counseling about weight loss, dietary caloric restriction, increased exercise, and perhaps immediate oral hypoglycemic drug intervention. The assumption is that type 2 diabetes is a slowly evolving disease for which acute intervention is less important than meaningful changes in the factors that contributed to the disease and ultimately influence long-term outcomes. The study by Weng and colleagues suggests that we reconsider the initial treatment of type 2 diabetes. This well-designed study found that achieving glycemic control within the first few weeks of initial diagnosis, especially with intensive insulin therapy, resulted in rapid blood glucose control, with sustained effects for 1 year. More surprising is the observation that the rapidly controlled glycemia can be maintained without continuing drug intervention in the first year after diagnosis. If this finding is validated in further studies, it would be an important contribution to how type 2 diabetes is managed at the time of diagnosis. We do not know whether these favorable outcomes result from the drug treatments alone or from the influence of the overall care process that probably included a more intense interaction with patients throughout the study. Description of the dietary and exercise requirements of the study were not provided but might help to explain subsequent improvements in -cell function. We also do not know how patients were counseled and monitored for treatment adherence, a critical influence in maintaining glycemic control without medication use. Nonetheless, the results of this study have important implications for better understanding the underlying pathophysiology and strategies for initiating care at diagnosis of type 2 diabetes.

Intravenous Fluid Administration

This chapter highlights several considerations in the use of intravenous (IV) fluids in the geriatric patient, specifically sodium and water. It emphasizes that these key elements of routine intravenous fluid orders are also body nutrients, required in limits to avoid the adverse consequences of either excess or deficit. A review of basic sodium and water distribution, regulation, and excretion is provided. The sodium content of various salt-containing fluids and supplements is presented as well as general principles underlying sodium administration. The goal of intravenous fluid administration is to carefully achieve and maintain a euvolemic and isotonic environment within the body as well as to provide for a variety of nutritional and pharmacologic interventions. The selection of an appropriate IV solution is dependent upon the fluid volume and electrolyte status of the individual patient as well as any additional specific therapeutic goals.

Review: advice on low-fat diets is not better than other weight-reducing diets for sustaining weight loss in obesity.

Study selection Studies were selected if they were randomised controlled trials (RCTs) with ≥ 6 months follow-up that compared advice on low-fat diets (treatment group) with other weight reducing diets (control group), the primary purpose of the study was weight loss, and participants were adults ( ≥ 18 y of age) who were overweight or obese (body mass index > 25 kg/m) at baseline. RCTs including pregnant women or patients with serious medical conditions were excluded.

Sustaining the structure of the professional self.

No abstract available.

Regular exercise was associated with a reduced incidence of diabetes mellitus among U.S. male physicians

Source Citation Manson JE, Nathan DM, Krolewski AS, et al. A prospective study of exercise and incidence of diabetes among U.S. male physicians. JAMA. 1992 Jul 1;268:63-7.

Very-low-calorie diet for obese type 2 diabetic patients

Source Citation Wing RR, Marcus MD, Salata R, et al. Effects of a very-low-calorie diet on long-term glycemic control in obese type 2 diabetic subjects. Arch Intern Med. 1991 Jul;151:1334-40.