Kalli Varaklis

Randomized controlled trial of vaginal misoprostol and intracervical prostaglandin E2 gel for induction of labor at term

Objective To compare misoprostol 25 μg administered at 2-hour intervals with intracervical prostaglandin (PG) E2 in women with Bishop scores of 5 or less. Methods Subjects were randomly assigned to receive either misoprostol 25 μg every 2 hours or a commercially available intracervical preparation containing 0.5 mg of PGE2 gel administered at 6-hour intervals for a maximum of two doses. Results Women who received misoprostol experienced a significantly reduced mean time (± standard deviation) from drug administration to onset of three contractions in 10 minutes, 6.7 ± 5.8 versus 12.4 ± 9.6 hours (P = .007). Mean time to rupture of membranes was also shorter in the misoprostol group, 9.7 ± 5.5 versus 13.6 ± 6.8 hours (P = .01), as was the mean time to delivery, 16.0 ± 7.7 versus 22.4 ± 10.9 hours (P = .006). Three patients in the misoprostol group experienced uterine hypertonus but no related fetal morbidity. Conclusion Misoprostol is more effective than intracervical PGE2 in bringing about labor and delivery, but further work is needed to determine the ideal dosing regimen.

Predictive Value of History and Physical Examination in Patients With Suspected Ectopic Pregnancy

STUDY OBJECTIVE To identify historical and physical examination findings that are predictive of ectopic pregnancy (EP) in pregnant patients with abdominal pain or bleeding. METHODS This study was conducted in an urban academic emergency department as a prospective observational study of consecutive patients from August 1, 1991, to August 31, 1992, who had abdominal pain or vaginal bleeding and a positive beta-human chorionic gonadotropin level. Patients were excluded if they had a diagnostic ultrasound during a previous visit, or if the uterine size was larger than 12 weeks by pelvic examination. Data were analyzed using chi2 with a P value less than. 05 identified as significant. Odds ratios were determined for significant variables. A classification and regression tree analysis was then performed using the predictive variables to derive a decision tree. RESULTS Four hundred forty-one patients were enrolled, 57 of whom (13%) had an EP. Factors by history that increased the risk of EP included pain that was described as moderate to severe, lateral, or sharp. Pain located in the midline decreased the risk of EP. A history of previous intrauterine device use, infertility, prior pelvic surgery, or tubal ligation were each found to be predictive. On physical examination, the presence of peritoneal signs, cervical motion tenderness, or lateral or bilateral abdominal or pelvic tenderness increased the risk of EP. A uterine size larger than 8 weeks by pelvic examination decreased the risk of EP. Combinations of predictive variables identified subsets of patients with either an increased or decreased frequency of EP, but in no case was a combination identified that would confirm or exclude this diagnosis with a high degree of certainty. CONCLUSION History and physical examination findings predictive of EP were identified. However, no constellation of findings could confirm or exclude this diagnosis with a high degree of reliability.

Feedback for Learners in Medical Education: What Is Known? A Scoping Review

Purpose To conduct a scoping review of the literature on feedback for learners in medical education. Method In 2015–2016, the authors searched the Ovid MEDLINE, ERIC, CINAHL, ProQuest Dissertations and Theses Global, Web of Science, and Scopus databases and seven medical education journals (via OvidSP) for articles published January 1980–December 2015. Two reviewers screened articles for eligibility with inclusion criteria. All authors extracted key data and analyzed data descriptively. Results The authors included 650 articles in the review. More than half (n = 341) were published during 2010–2015. Many centered on medical students (n = 274) or residents (n = 192); some included learners from other disciplines (n = 57). Most (n = 633) described methods used for giving feedback; some (n = 95) described opinions and recommendations regarding feedback. Few studies assessed approaches to feedback with randomized, educational trials (n = 49) or described changes in learner behavior after feedback (n = 49). Even fewer assessed the impact of feedback on patient outcomes (n = 28). Conclusions Feedback is considered an important means of improving learner performance, as evidenced by the number of articles outlining recommendations for feedback approaches. The literature on feedback for learners in medical education is broad, fairly recent, and generally describes new or altered curricular approaches that involve feedback for learners. High-quality, evidence-based recommendations for feedback are lacking. In addition to highlighting calls to reassess the concepts and complex nature of feedback interactions, the authors identify several areas that require further investigation.

Commentary: Principle-Based Teaching Competencies

The emphasis on resident competencies advocated by the Accreditation Council for Graduate Medical Education and other medical educators1 has brought new focus on the teaching competencies of our faculty. The expectation that teaching faculty possess a minimum level of teaching competency has been under discussion at our institution. In our recent (2008) peer-reviewed workshop at the Association of American Medical Colleges, we found that, among the 28 participants, no school was providing faculty development for competence in teaching. As increasing public scrutiny focuses on the medical professions, medical educators will be asked to be more accountable for training programs they are involved in and the teaching skills they possess.2

Organizing graduate medical education programs into communities of practice

Background A new organizational model of educational administrative support was instituted in the Department of Medical Education (DME) to better meet increasing national accreditation demands. Residency and fellowship programs were organized into four ‘Communities of Practice’ (CoOPs) based on discipline similarity, number of learners, and geographic location. Program coordinator reporting lines were shifted from individual departments to a centralized reporting structure within the DME. The goal of this project was to assess the impact on those most affected by the change. Methods This was a mixed methods study that utilized structured interviews and the Organizational Culture Assessment Instrument (OCAI). Eleven members of the newly formed CoOPs participated in the study. Results Three major themes emerged after review and coding of the interview transcripts: improved group identity, improved availability of resources, and increased opportunity for professional growth. OCAI results indicated that respondents are committed to the DME and perceived the culture to be empowering. The ‘preferred culture’ was very similar to the culture at the time of the study, with some indication that DME employees are ready for more creativity and innovation in the future. Conclusion Reorganization within the DME of residency programs into CoOPs was overwhelmingly perceived as a positive change. Improved resources and accountability may position our DME to better handle the increasing complexity of graduate medical education.

The research contributions of predominantly North American Family Medicine educators to medical learner feedback: a descriptive analysis following a scoping review

Abstract Background and objectives: In 2016, we performed a scoping review as a means of mapping what is known in the literature about feedback to medical learners. In this descriptive analysis, we explore a subset of the results to assess the contributions of predominantly North American family medicine educators to the feedback literature. Methods: Nineteen articles extracted from our original scoping review plus six articles identified from an additional search of the journal Family Medicine are described in-depth. Results: The proportion of articles involving family medicine educators identified in our scoping review is small (n=19/650, 3%) and the total remains low (25) after including additional articles (n=6) from a Family Medicine search. They encompass a broad range of feedback methods and content areas. They primarily originated in the United States (n=19) and Canada (n=3) within Family Medicine Departments (n=20) and encompass a variety of scientific and educational research methodologies. Conclusions: The contributions of predominantly North American Family Medicine educators to the literature on feedback to learners are sparse in number and employ a variety of focus areas and methodological approaches. More studies are needed to assess for areas of education research where family physicians could make valuable contributions.

Defining entrustable professional activities for residency/fellowship programme directors

istrative problems and topics were also welcome. Anonymity was maintained entirely for both faculty and residents so that an individual who suggested a topic remained nameless. What lessons were learned? Open discussion and evaluation of all available information can lead to the best possible solution for a group. The result of the town hall meeting has been enhanced and secure open communication between faculty members, residents and staff. The meeting has reassured residents that the faculty hears their voices, and vice versa. Additionally, we are often able to move forward on a topic quickly and to find a resolution or compromise that satisfies each party, and within 1 hour we can cover several aspects within a topic. The open forum style has improved rapport between the groups as residents feel that they can express themselves honestly, which has facilitated more tangible change. For example, there was significant controversy over a recent change to our ‘new patient’ template, but in this setting we were all able to agree on the optimal format and to finalise a plan within minutes, something that is not achievable by exchanging e-mails with numerous attachments during busy clinic and academic schedules. We have also addressed more controversial topics, including long-standing regulations. Although one party may not see the exact change they hope for, the open communication allows the freedom to suggest alternatives or even other evolving problems. We will continue this forum to ensure cooperation and communication in the future as it has become an invaluable part of our programme.