Jeffrey P. Schaefer

Hyperhomocyst(e)inemia and the prevalence of atherosclerotic vascular disease in patients with end-stage renal disease

Hyperhomocyst(e)inemia is now recognized as an independent risk factor for atherosclerotic cardiovascular disease in patients with normal renal function. Hyperhomocyst(e)inemia is common in patients with chronic renal failure. This study is designed to look for an association between hyperhomocyst(e)inemia and atherosclerotic vascular disease in patients with end-stage renal disease (ESRD). Two hundred eighteen patients undergoing hemodialysis were enrolled onto the study and had predialysis bloodwork performed for total homocyst(e)ine, red blood cell folate, and vitamin B(12) levels. A history of clinically significant atherosclerotic vascular disease (ischemic heart disease, cerebrovascular disease, or peripheral vascular disease) was elicited by patient questionnaire and verified by careful inpatient and outpatient chart review. Atherosclerotic vascular disease was present in 45.9% of patients. Mean homocyst(e)ine concentration was 26.7 micromol/L (95% confidence interval [CI], 25.0 to 28.4) overall. Mean homocyst(e)ine concentration was 28.6 micromol/L (95% CI, 25.6 to 31.7) and 25.0 micromol/L (95% CI, 23.2 to 26.8) in patients with and without atherosclerotic disease, respectively (P = 0.036). The adjusted odds ratio for atherosclerotic disease was 2.12 (95% CI, 1.03 to 4.39) for those subjects with a homocyst(e)ine level in the highest quartile compared with the lowest 3 quartiles. In the 126 men, the adjusted odds ratio for atherosclerotic disease was 3.4 (95% CI, 1. 24 to 9.42) for those with homocyst(e)ine levels in the highest quartile compared with the lowest 3 quartiles. No association was found between homocyst(e)ine level and atherosclerotic disease in women. In conclusion, there is an association between hyperhomocyst(e)inemia and atherosclerotic vascular disease in patients undergoing dialysis. Prospective studies need to further examine the relationship between homocyst(e)ine level and atherosclerosis in women with ESRD.

Diagnosing technical competence in six bedside procedures: comparing checklists and a global rating scale in the assessment of resident performance.

Purpose To compare procedure-specific checklists and a global rating scale in assessing technical competence. Method Two trained raters used procedure-specific checklists and a global rating scale to independently evaluate 218 video-recorded performances of six bedside procedures of varying complexity for technical competence. The procedures were completed by 47 residents participating in a formative simulation-based objective structured clinical examination at the University of Calgary in 2011. Pass/fail (competent/not competent) decisions were based on an overall global assessment item on the global rating scale. Raters provided written comments on performances they deemed not competent. Checklist minimum passing levels were set using traditional standard-setting methods. Results For each procedure, the global rating scale demonstrated higher internal reliability and lower interrater reliability than the checklist. However, interrater reliability was almost perfect for decisions on competence using the overall global assessment (Kappa range: 0.84–1.00). Clinically significant procedural errors were most often cited as reasons for ratings of not competent. Using checklist scores to diagnose competence demonstrated acceptable discrimination: The area under the curve ranged from 0.84 (95% CI 0.72–0.97) to 0.93 (95% CI 0.82–1.00). Checklist minimum passing levels demonstrated high sensitivity but low specificity for diagnosing competence. Conclusions Assessment using a global rating scale may be superior to assessment using a checklist for evaluation of technical competence. Traditional standard-setting methods may establish checklist cut scores with too-low specificity: High checklist scores did not rule out incompetence. The role of clinically significant errors in determining procedural competence should be further evaluated.

Somatic awareness in the clinical care of patients with body distress symptoms.

The purpose of this paper is to provide primary care physicians and medical specialists with an experiential psychosomatic framework for understanding patients with body distress symptoms. The framework relies on somatic awareness, a normal part of consciousness, to resolve the dualism inherent in conventional multidisciplinary approaches. Somatic awareness represents a guiding healing heuristic which acknowledges the validity of the patients physical symptoms and uses body sensations to identify the psychological, physiological, and social factors needed for symptom self-regulation. The experiential approach is based on psychobiologic concepts which include bodily distress disorder, central sensitization, dysfunctional breathing, and contextual nature of mood.

Medical students’ attitudes towards treating patients with HIV: A 12-year follow-up study

Undergraduate medical trainees are likely to encounter patients infected with human immunodeficiency virus (HIV) during their careers. The identification of attitudes associated with unwillingness to treat HIV-infected patients is important in devising relevant curricula to prepare medical trainees for such encounters. While several studies have been performed to measure such attitudes, the vast majority is outdated, as medical and societal stigmas surrounding HIV have evolved considerably over time. We performed a cross-sectional survey of pre-clerkship medical students at an urban Canadian university using a published, standardized survey instrument administered to a different cohort 12 years prior (Carter et al. 1996). The goal of the survey was to measure the willingness of medical trainees to treat patients with HIV and HIV-associated attitudes. Linear regression was used to identify correlations between attitudes and the Student’s t-test and Fisher’s exact test were used to identify significant associations between desired outcomes. A total of 201 students (81.4%) completed the survey. Willingness to treat patients with HIV was rated as 6.16 0.74 out of maximum value of 7 and compared with results from 12 years prior, students were significantly more willing to treat patients with HIV (p5 0.01). Factors most strongly correlated with unwillingness to treat HIV-infected patients were fear of infection and homophobia (R1⁄4 0.50 and 0.49, respectively), while a stronger sense of professional obligation was weakly associated with willingness to treat (R1⁄4 0.37). Interestingly, neither fear of infection nor homophobia scores showed a significant change over the 12-year interval and sense of professional obligation actually decreased (p5 0.01). Stratified by age, younger students were less willing to treat patients with HIV, more fearful of infection and scored higher on homophobia scales (p5 0.05). Compared to first-year students, second-year students were more willing to treat HIV-infected patients, felt a stronger sense of professional obligation, and scored lower on homophobia scales (p5 0.05). This is cause for optimism as previous studies showed no changes in attitudes or a declining willingness to treat HIV patients as students advanced through their training (Weyant et al. 1993) Medical school provides a unique opportunity to educate future physicians about vulnerable populations such as HIVinfected patients who continue to face social stigma and challenges in access to healthcare. While medical trainees are now more willing to treat patients with HIV than their successors, fear of infection and homophobia remain barriers to patient care that should be addressed in medical curricula. Shawn Hoffart, Department of Kinesiology, Alberta Health Services, Calgary, AB, Canada, George M. Ibrahim, Division of Neurosurgery, University of Toronto, Toronto, ON, Canada, Russell A. Lam, Department of Pediatrics, Queen’s University, Kingston, ON, Canada, Evan P. Minty, Department of Medicine, University of Calgary, Calgary, AB, Canada, Michelle Theam, Department of Anesthesia, University of Alberta, Alberta, Canada, Jeffrey P. Schaefer, Foothills Medical Centre, 1403 29 Street NW, Calgary, AB T2N 2T9, Canada. E-mail: george.m.ibrahim@gmail.com

Estimation of post-test probabilities by residents: Bayesian reasoning versus heuristics?

Although the process of diagnosing invariably begins with a heuristic, we encourage our learners to support their diagnoses by analytical cognitive processes, such as Bayesian reasoning, in an attempt to mitigate the effects of heuristics on diagnosing. There are, however, limited data on the use ± impact of Bayesian reasoning on the accuracy of disease probability estimates. In this study our objective was to explore whether Internal Medicine residents use a Bayesian process to estimate disease probabilities by comparing their disease probability estimates to literature-derived Bayesian post-test probabilities. We gave 35 Internal Medicine residents four clinical vignettes in the form of a referral letter and asked them to estimate the post-test probability of the target condition in each case. We then compared these to literature-derived probabilities. For each vignette the estimated probability was significantly different from the literature-derived probability. For the two cases with low literature-derived probability our participants significantly overestimated the probability of these target conditions being the correct diagnosis, whereas for the two cases with high literature-derived probability the estimated probability was significantly lower than the calculated value. Our results suggest that residents generate inaccurate post-test probability estimates. Possible explanations for this include ineffective application of Bayesian reasoning, attribute substitution whereby a complex cognitive task is replaced by an easier one (e.g., a heuristic), or systematic rater bias, such as central tendency bias. Further studies are needed to identify the reasons for inaccuracy of disease probability estimates and to explore ways of improving accuracy.

Glycemic Control and Use of the Insulin Sliding Scale in Hospitalized Patients with Diabetes

&NA; This study assessed the extent of use of the subcutaneous insulin sliding scale (ISS) with hospitalized medical patients and examined the association between ISS use and glucose control. Despite some concerns about efficacy and suitability, the ISS is often used in the hospital studied. Researchers reviewed records of patients with a secondary diagnosis of diabetes who were admitted to the medical teaching unit of a tertiary care hospital. On day 1, 45.2% of patients were on an ISS alone. Patients on an ISS were more likely to experience hyperglycemia compared with patients on scheduled regimens, but they also had fewer hypoglycemic episodes.

Procedural certification program: Enhancing resident procedural teaching skills

13 residents on how to develop a Quality Improvement (QI) project during their one-month rotation at the clinic. Using the Plan, Do, Study, Act (PDSA) model, residents implemented multiple interventions to improve the rate of standardized developmental screenings at well-child visits for children aged 9 months to 36 months (N1⁄4 1061) between January 2009 and June 2010. The rate of standardized developmental screening increased from 7% to 56% after residents initiated QI interventions. Barriers were encountered during the project, such as limited education and socioeconomic resources of the patient population, scarce time in the clinic setting, and suboptimal resident/staff knowledge of developmental screening tools and recommendations. By familiarizing themselves with the barriers that existed, and taking advantage of the AAP’s mission for health promotion and connection to communitybased resources, the residents were able to positively impact the developmental screening rates in the clinic. The residents’ successful outcomes suggest that combining resident education and AAP mentorship in QI interventions can lead to substantial gains in the quality of patient care (Akins & Handel 2009). In this case, the rate of developmental screening at a general pediatric clinic improved as a result of this collaborative effort.

In-group bias in residency selection

Background: More than half of all Canadian medical graduates match to residency programs within the same university as their medical school. Here we describe two studies designed to explore whether there is partiality for internal applicants in the resident selection process. Methods: We first performed an observational study in which we compared the ratings of 14 ‘internal’ and 89 ‘external’ applicants to the University of Calgary Internal Medicine Training Program by resident and faculty raters. Following this we then asked residents to rate anonymous application packages in which we manipulated applicants’ affiliation to our training program. Results: In our first study, we found that residents rated internal applicants significantly higher for both application packages (mean (SD)) rating for internal versus external applicants (4.86 (0.36) vs. 4.36 (0.57), d = 1.05, p = 0.002) and interviews (4.93 (0.27) vs. 4.36 (0.7), d = 1.07, p = 0.003). There was no difference in the faculty ratings of internal and external applicants. In our second study, we found that residents rated applicants with an affiliation to our program – either attending the local medical school or having completed an elective – higher than applicants with no affiliation to our program. Conclusions: Our finding support in-group bias during resident selection, possibly due to the interdependent relationship between residents and students. Considering the career implications of residency matching, we feel that further studies are needed to identify and mitigate sources of bias in the residency application process.

Teaching Physicians, Nurses, and Mental Health Professionals About Medically Unexplained Symptoms: A Course on the Mindful Body at the University of Calgary

Content on integrative healthcare and complementary and alternative medicine is being taught in hundreds of educational programs across the country. Nursing, medical, osteopathic, chiropractic, acupuncture, naturopathic, and other programs are finding creative and innovative ways to include these approaches in new models of education and practice. This column spotlights such innovations in integrative healthcare and CAM education and presents readers with specific educational interventions they can adapt into new or ongoing educational efforts at their institution or programs. We invite readers to submit brief descriptions of efforts in their institutions that reflect the creativity, diversity, and interdisciplinary nature of the field. Please submit to Dr Sierpina at vssierpi@utmb.edu or Dr Kreitzer at kreit003@umn.edu. Submissions should be no more than 500 to 1,500 words. Please include any Web site or other resource that is relevant, as well as contact information.