Rein Zwierstra

BEME systematic review: Predictive values of measurements obtained in medical schools and future performance in medical practice

Background: Effectiveness of medical education programs is most meaningfully measured as performance of its graduates. Objectives: To assess the value of measurements obtained in medical schools in predicting future performance in medical practice. Methods: Search strategy: The English literature from 1955 to 2004 was searched using MEDLINE, Embase, Cochranes EPOC (Effective Practice and Organization of Care Group), Controlled Trial databases, ERIC, British Education Index, Psych Info, Timelit, Web of Science and hand searching of medical education journals. Inclusion & exclusions: Selected studies included students assessed or followed up to internship, residency and/or practice after postgraduate training. Assessment systems and instruments studied (Predictors) were the National Board Medical Examinations (NBME) I and II, preclinical and clerkship grade-point average, Observed Standardized Clinical Examination scores and Undergraduate Deans rankings and honors society. Outcome measures were residency supervisor ratings, NBME III, residency in-training examinations, American Specialty Board examination scores, and on-the-job practice performance. Data extraction: Data were extracted by using a modification of the BEME data extraction form study objectives, design, sample variables, statistical analysis and results. All included studies are summarized in a tabular form. Data analysis and synthesis: Quantitative meta-analysis and qualitative approaches were used for data analysis and synthesis including the methodological quality of the studies included. Results: Of 569 studies retrieved with our search strategy, 175 full text studies were reviewed. A total of 38 studies met our inclusion criteria and 19 had sufficient data to be included in a meta-analysis of correlation coefficients. The highest correlation between predictor and outcome was NBME Part II and NBME Part III, r = 0.72, 95% CI 0.30–0.49 and the lowest between NBME I and supervisor rating during residency, r = 0.22, 95% CI 0.13–0.30. The approach to studying the predictive value of assessment tools varied widely between studies and no consistent approach could be identified. Overall, undergraduate grades and rankings were moderately correlated with internship and residency performance. Performance on similar instruments was more closely correlated. Studies assessing practice performance beyond postgraduate training programs were few. Conclusions: There is a need for a more consistent and systematic approach to studies of the effectiveness of undergraduate assessment systems and tools and their predictive value. Although existing tools do appear to have low to moderate correlation with postgraduate training performance, little is known about their relationship to longer-term practice patterns and outcomes.

The development of a scale to measure personal reflection in medical practice and education

Aim: Personal reflection is important for acquiring, maintaining and enhancing balanced medical professionalism. A new scale, the Groningen Reflection Ability Scale (GRAS), was developed to measure the personal reflection ability of medical students. Method: Explorative literature study was conducted to gather an initial pool of items. Item selection took place using qualitative and quantitative methods. Medical teachers screened the initial item-pool on relevance, expert-analysis was used for screening the fidelity to the criterion and large samples of medical students and medical teachers were used to investigate the psychometric characteristics of the items. Finally, explorative factor analysis was used to investigate the structure of the scale. Results: The psychometric quality and content validity of the GRAS are satisfactory. The items cover three aspects of personal reflection: self-reflection, empathetic reflection and reflective communication. The 23-item scale proved to be easy to complete and to administer. Conclusion: The GRAS is a practical measurement instrument that yields reliable data that contribute to valid inferences about the personal reflection ability of medical students and doctors, both at individual and group level.

Prognosis of extrahepatic biliary atresia.

We carried out a retrospective investigation of the 89 patients with extrahepatic biliary atresia born in The Netherlands during a 10 year period. Of these 89 patients 10 had a diagnostic laparotomy only. Eight patients had an anastomosis between the proximal bile duct and the intestine, and the remaining 71 had hepatic portoenterostomies. Bile drainage was re-established in 46 (65%). After successful hepatic portoenterostomy the development of cholangitis was the most important determinant of long term survival; five year survival was 54% in the 19 patients who had cholangitis and 91% in the 27 who did not. In the whole group of 71 patients the five year survival was 47%. Seventeen patients were at least 5 years of age at the time of writing, three of whom had had liver transplantation. Three patients have cirrhosis and hyperbilirubinaemia, and the other 11 have normal bilirubin concentrations and normal or slightly raised transaminase activities. To improve these results early surgical intervention in all children with extrahepatic biliary atresia is necessary, as are better methods of prophylaxis and treatment of cholangitis.

Oncological implications of RET gene mutations in Hirschsprung’s disease

Background—Germline mutations of the RET proto-oncogene identical to those found in the tumour predisposition syndrome multiple endocrine neoplasia type 2A (MEN2A), were detected in 2.5–5% of sporadic and familial cases of Hirschsprung’s disease. Some patients with Hirschsprung’s disease may therefore be exposed to a highly increased risk of tumours. Aims—To define clinical use of RET gene testing in Hirschsprung’s disease and related patient management from an oncological point of view. Methods—Sixty patients with Hirschsprung’s disease were screened for RET mutations. In three, MEN2A type RET mutations were detected. Case reports for these three patients are presented. Results and conclusions—Only 22 families or sporadic patients with Hirschsprung’s disease and MEN2A type RET mutations have been reported. Therefore, it is difficult to predict tumour risk for patients with familial or sporadic Hirschsprung’s disease, and their relatives, who carry these mutations. For these mutation carriers, periodic screening for tumours as in MEN2A is advised, but prophylactic thyroidectomy is offered hesitantly. RET gene testing in familial or sporadic Hirschsprung’s disease is not recommended at present outside a complete clinical research setting. In combined MEN2A/Hirschsprung’s disease families RET gene testing, tumour screening, and prophylactic thyroidectomy are indicated as in MEN2A.

Nesidioblastosis and endocrine hyperplasia of the pancreas: a secondary phenomenon.

Diffuse endocrine cell proliferation (nesidioblastosis) and islet cell hyperplasia are considered causes of organic hyperinsulinism but have not been distinguished (by histometric or immunohistologic methods) from the normally variable pancreatic islet cell population during development and in adults. Therefore, in this study morphologic, immunohistologic (to detect insulin, glucagon, somatostatin, and pancreatic polypeptide), and morphometric features were evaluated in 1) normal pancreases (from fetal to adult; n = 49); 2) pancreases from patients with nesidioblastosis (n = 5); and 3) tumor-associated pancreases (TAP) from patients with insulin-producing islet cell tumors (n = 8). The study of normal postnatal development revealed that all features of fetal development remain present after birth and that the diagnosis of any diffuse endocrine disorder should therefore be based essentially on quantitative histometric parameters (total endocrine area, islet size distribution, distribution of each endocrine cell type). With these parameters endocrine cell hyperplasia was demonstrated in TAP from adults due to increased numbers of A and D cells. However, in the cases previously diagnosed as pathologic nesidioblastosis, all parameters were within the normal range. Thus, nesidioblastosis does not appear to be a pathologic entity. Careful re-examination of the pancreases, prompted by these data, revealed small islet cell tumors in three of these five cases. It is concluded that the endocrine pancreas can react rapidly, both morphologically and functionally, to changes in hormonal feedback, e.g., islet cell tumors. Therefore, the observation of a diffuse islet cell disorder in a patient with hyperinsulinism should not be considered an indication that an islet cell tumor is not present.

The Effect of Enhanced Experiential Learning on the Personal Reflection of Undergraduate Medical Students

Abstract Objective: This study’s aim was to test the expectation that enhanced experiential learning is an effective educational method that encourages personal reflection in medical students. Methods: Using a pre post-test follow-up design, the level of the personal reflection ability of an exposure group of first-year medical students participating in a new enhanced experiential learning program was compared to that of a control group of second- and third-year medical students participating in a standard problem-based learning program. Personal reflection was assessed using the Groningen Reflection Ability Scale (GRAS). Students’ growth in reflection was analyzed with multilevel analysis. Results: After one year, first-year medical students in the exposure group achieved a level of personal reflection comparable to that reached by students of the control group in their third year. This difference in growth of reflection was statistically significant (p < .001), with a small effect size (effect size = 0.18). The reflection growth curve of the control group declined slightly in the third year as a function of study time. Conclusion: Enhanced experiential learning has a positive effect on the personal reflection ability of undergraduate medical students.

Bilateral split hand/foot malformation and inv(7)(p22q21.3).

A boy with typical tetramelic split hands and feet is described. In addition, there was a large arteriovenous malformation of the right arm. Chromosome studies showed a pericentric inversion of chromosome 7: 46,XY,inv(7)(p22q21.3). Inspection of the extremities and chromosome studies in the parents were normal. This case confirms the suggested localisation of a locus, important for early limb differentiation, on the long arm of chromosome 7, most probably in the chromosomal region 7q21.2-7q21.3. Previously reported cases are reviewed briefly.

Limited role of meta-iodobenzylguanidine scintigraphy in imaging phaeochromocytoma in patients with multiple endocrine neoplasia type II.

OBJECTIVE To compare diagnostic applicability of combined computed tomography (CT) and magnetic resonance imaging (MRI), with that of meta-iodobenzylguanidine (MIBG) scintigraphy in the preoperative localisation of MEN II related phaeochromocytoma. DESIGN Retrospective study SETTING University hospital, The Netherlands. MATERIALS 17 patients with MEN II patients (33 adrenal glands) who were operated on for phaeochromocytoma. MIBG scintigraphy, CT and MRI were used to localize phaeochromocytoma. Histopathologically, an adrenomedullary lesion more than 1 cm in size was classified as a phaeochromocytoma. MAIN OUTCOME MEASURES Sensitivity, specificity, and diagnostic accuracy of combined CT and MRI and MIBG scintigraphy, compared with histopathological findings. RESULTS Sensitivity of combined CT and MRI (27 adrenal glands) was 87%, with a specificity of 100% and a diagnostic accuracy of 89%. MIBG scintigraphy (31 adrenal glands) had a sensitivity of 92%, a specificity of only 17%, and a diagnostic accuracy of 77%. CONCLUSION If unilateral adrenalectomy is done when only one adrenal gland contains a phaeochromocytoma, then MRI should be the method of choice for localising MEN type II related phaeochromocytoma. MIBG scintigraphy can be restricted to those patients in whom MRI does not show a tumour.

MATERNOEMBRYONIC TRANSFUSION AND CONGENITAL-MALFORMATIONS - AN EXPERIMENTAL-STUDY USING RAT EMBRYOS

In an experimental study, using an in vitro whole rat embryo culture, the effects of a maternoembryonic transfusion and immunologic interaction on the development of ten-day-old rat embryos (stages 8 to 10 somites) has been studied. Transplacental transfusion has been simulated by embryonic intracardiac microinjection of 0.1 to 0.5 microL immunologically active rat serum. After an incubation of 24 and 48 hours, respectively, the embryos were killed. All tested embryos have survived the incubation period. On microscopic examination of the tested embryos those that were taken from the incubator after 24 hours showed no signs of pathogenic cell degeneration, while the embryos that were taken from the incubator after 48 hours all had localized lesions with pathogenic cell degeneration in one or multiple major structures. The neurectoderm and endoderm seem to be the most sensitive tissues in this period of organogenesis. The results suggest that immunologic reaction to transplacental transfusion of maternal serum may lead to congenital malformations.

Docentprofessionalisering: de stand van zaken anno 2006

Op basis van een artikel dat door dezelfde auteurs in 1994 over docentprofessionalisering is geschreven, wordt een overzicht gegeven van de ontwikkelingen en de huidige stand van zaken op dit gebied. Het ter beschikking komen van het Raamplan 1994 artsopleiding en het Raamplan 2001 artsopleiding, de curriculumvernieuwingen die overal in ons land zijn ingevoerd en de veranderde eisen die aan de vervolgopleidingen en opleiders worden gesteld, hebben geleid tot een toegenomen bewustwording van de noodzaak van docenttraining. Dergelijke trainingen blijken niet alleen in de UMC’s, maar vooral ook in de opleidingsregio op locatie te worden gegeven. In de onderwijs- en opleidingsregio Noord en Oost-Nederland is het aantal deelnemers aan dergelijke trainingen sinds 1994 meer dan verviervoudigd. Toekomstige ontwikkelingen worden verwacht in het tot standkomen van docentkwalificaties, de deelname aan cursussen door artsassistenten, coaching in de dagelijkse onderwijspraktijk en in onderzoek op het gebied van ‘best evidence based medical education’. (Zwierstra RP, Venekamp R, Koppelman GH. Docentprofessionalisering: de stand van zaken anno 2006. Tijdschrift voor Medisch Onderwijs 2006;25(6):279-284.)