Susan Tallett

A review of the evaluation of clinical teaching: new perspectives and challenges *

This article discusses the importance of the process of evaluation of clinical teaching for the individual teacher and for the programme. Measurement principles, including validity, reliability, efficiency and feasibility, and methods to evaluate clinical teaching are reviewed.

Clinical teaching: maintaining an educational role for doctors in the new health care environment

Good clinical teaching is central to medical education but there is concern about maintaining this in contemporary, pressured health care environments. This paper aims to demonstrate that good clinical practice is at the heart of good clinical teaching.

Brief Psychoeducational Parenting Program: An Evaluation and 1-Year Follow-up

OBJECTIVE Despite recognition of the need for parenting interventions to prevent childhood behavioral problems, few community programs have been evaluated. This report describes the randomized controlled evaluation of a four-session psychoeducational group for parents of preschoolers with behavior problems, delivered in community agencies. METHOD In 1998, 222 primary caregivers, recruited through community ads, filled out questionnaires on parenting practices and child behavior. Parents were randomly assigned to immediate intervention or a wait-list control. The intervention comprised three weekly group sessions and a 1-month booster, the focus being to support effective discipline (using the video 1-2-3 Magic) and to reduce parent-child conflict. RESULTS Using an intent-to-treat analysis, repeated-measures analyses of variance indicated that the parents who received the intervention reported significantly greater improvement in parenting practices and a significantly greater reduction in child problem behavior than the control group. The gains in positive parenting behaviors were maintained at 1-year follow-up in a subset of the experimental group. CONCLUSIONS This brief intervention program may be a useful first intervention for parents of young children with behavior problems, as it seems both acceptable and reasonably effective.

Conflicting messages: examining the dynamics of leadership on interprofessional teams.

Purpose Despite the importance of leadership in interprofessional health care teams, little is understood about how it is enacted. The literature emphasizes a collaborative approach of shared leadership, but this may be challenging for clinicians working within the traditionally hierarchical health care system. Method Using case study methodology, the authors collected observation and interview data from five interprofessional health care teams working at teaching hospitals in urban Ontario, Canada. They interviewed 46 health care providers and conducted 139 hours of observation from January 2008 through June 2009. Results Although the members of the interprofessional teams agreed about the importance of collaborative leadership and discussed ways in which their teams tried to achieve it, evidence indicated that the actual enactment of collaborative leadership was a challenge. The participating physicians indicated a belief that their teams functioned nonhierarchically, but reports from the nonphysician clinicians and the authors’ observation data revealed that hierarchical behaviors persisted, even from those who most vehemently denied the presence of hierarchies on their teams. Conclusions A collaborative approach to leadership may be challenging for interprofessional teams embedded in traditional health care, education, and medical-legal systems that reinforce the idea that physicians sit at the top of the hierarchy. By openly recognizing and discussing the tensions between traditional and interprofessional discourses of collaborative leadership, it may be possible to help interprofessional teams, physicians and clinicians alike, work together more effectively.

Patterns of Parental Bereavement following the Loss of a Child and Related Factors

This study investigated the patterns of parental bereavement in 20 parents who have lost a child to cancer, congenital heart disease, meningitis, or drowning in the last 19 months, using semi-structured interviews and standardized questionnaires of depression and grief. Qualitative content analysis of interviews identified three bereavement patterns: The majority of parents (65%) presented uncomplicated, Integrated Grief, five mothers were Consumed by Grief, and one mother and one father expressed Minimal Grief. Quotes from parents exemplified these patterns. Parental gender, symptoms of depression, and pre-death relationship between parents and their deceased child differentially related to these patterns. Having surviving children, social support, and being active appeared to help to integrate grief into daily life. These findings illustrate differential patterns of parental bereavement and related factors, information that has important implications for identifying at-risk parents for complicated bereavement.

Do child and/or parent bereavement programs work?

Bereavement programs for children and parents are becoming popular since there are more and more neonatal intensive care programs, pediatric oncology programs and pediatric intensive care programs offering these services. This paper addresses the following question: Do bereavement programs work? An overview of the literature dating back to 1964 was undertaken. Only papers dealing with treatment were reviewed. Randomized controlled trials were selected as presenting the best evidence for or against program effectiveness. Methodologic features such as description of the sample, comparability of treatment and control groups, description of the intervention, use of objective, valid, reproducible and blinded outcome measures, sample size calculations, thoroughness of follow-up and attention to clinical as well as statistical significance were assessed. Four randomized controlled trials were found in the literature search. Two of the studies showed benefit, two did not. All four suffered significant methodologic flaws. At this time it is unclear as to whether or not bereavement programs help families. Given the high costs of health care, it is important that studies be done to determine which families are likely to benefit from bereavement programs and what type of program is effective.

Measuring Educational Workload: A Pilot Study of Paper-based and PDA Tools

Background: Teaching is an important professional role for most faculty members in academic health sciences centres. Careful delineation of educational workload is needed to foster and reward teaching efforts, and to facilitate equitable allocation of resources. Aims: To promote recognition in teaching and facilitate equitable resource allocation, we developed, piloted, and qualitatively assessed a tool for delineating the educational workload of pediatric faculty in an academic health sciences centre. Methods: A prototype educational workload measurement tool was developed. Between 2002 and 2004, three successive phases of pilot implementation were conducted to (1) assess the face validity of the tool, (2) assess its feasibility, and (3) develop and assess the feasibility of a PDA (Personal Digital Assistant) version. Participants were interviewed regarding strengths, weaknesses, and barriers to completion. Data were analyzed for recurrent themes. Results: Faculty found that the tool was usable and represented a broad range of educational activities. The PDA format was easier to use and better received. Technical support would be imperative for long-term implementation. The greatest barriers to implementation were skepticism about the purpose of the tool and concerns that it would promote quantity over quality of teaching. Conclusion: We developed a usable tool to capture data on the diverse educational workload of pediatric faculty. PDA technology can be used to facilitate collection of workload data. Faculty skepticism is an important barrier that should be addressed in future work.

A Comparison of Canadian Pediatric Resident Career Plans in 1998 and 2006

OBJECTIVES. Studies of pediatric resident career plans and preferences help to forecast changes in the demographic profile and practice patterns of North American pediatricians, providing insights that can guide child health care and medical education policy making. With this study we aimed to compare 4 aspects of Canadian pediatric resident career plans in 1998 and 2006: (1) weekly work hours; (2) scope of practice; (3) professional activities; and (4) community size. METHODS. Canadian pediatric residents were invited to participate in a national cross-sectional survey to explore career plans and preferences in 1998 (mailing) and 2006 (on-line). RESULTS. Response rates were 69% in 1998 and 52% in 2006. In both survey years, the majority of respondents were female (69% and 73%, respectively). Overall, residents planned to work a similar number of weekly hours in both survey years (47.8 vs 48.8). Women planned to work significantly fewer hours than men; this gap was wider in 2006 than in 1998 (1998: 2.8 fewer hours; 2006: 7.8 fewer hours). After adjusted analysis, the association between proportion of time in primary care and study year became significant; however, time in consultant general or subspecialty pediatrics remained nonsignificantly changed. Residents planned to spend less time in clinical work in 2006 than 1998 (64.4% vs 58.1%), and more planned to work and reside in metropolitan areas (68% vs 78% of decided respondents). CONCLUSIONS. Between 1998 and 2006, there was no overall change in the number of hours that Canadian pediatric residents planned to work, but the gender gap widened because of an increase in planned weekly work hours among men. The results also suggest that new strategies may be needed to improve future pediatrician availability in small communities by addressing barriers to nonmetropolitan practice, especially for women.

When is a phaeo not a phaeo? Depression in an adolescent leading to a phaeochromocytoma-like biochemical profile

A previously healthy 14 4/12 year old boy presented with a 6 months history of a 10 kg weight loss, profuse sweating, fatigue, myalgia, sleep difficulties and loss of appetite. Other history was notable for ongoing feelings of sadness and anxiety, and three suicide attempts. On physical examination he was alert and oriented, his weight was 38.5 kg and his height 172 cm. The BMI SDS was −4.7. Blood pressure was 120/80 mm Hg and resting pulse was 130 bpm. He was sweating profusely, did not maintain eye contact, and was shivering. The remainder of his examination, including neurological was unremarkable. Diagnostic workup ruled out infectious and malignant causes. Thyroid function tests showed an increased fT4 level of 34.5 pmol/L (10–23), and a TSH level which was initially slightly low at 0.06 mIU/L (0.5–5.0), both of which normalized spontaneously in follow up tests. Medical psychiatry was also involved and provided supportive therapy and medication management. The sweating and resting tachycardia of 130 bpm prompted his primary team to perform an evaluation for pheochromocytoma with concerning results: his 24-hour urine collection revealed elevated dopamine and norepinephrine levels (Table 1). Table 1 Biochemical profile and clonidine suppression test results, and list of imaging studies performed To confirm the urinary catecholamine results and to localize the presumptive tumor, an extensive workup was carried out over the course of 1.5 years. Testing revealed a persistent elevation of urine catecholamines but negative anatomical and functional imaging studies (Table 1). In an effort to differentiate a true pheochromocytoma from a false positive elevation of catecholamines, a clonidine suppression test was carried out, which is reported to have 98%–100% specificity for pheochromocytoma, when positive.1 Our patient’s plasma normetanephrine and norepinephrine levels did not suppress sufficiently during the test, which was consistent with the presence of pheochromocytoma. During this test and the initial workup, the patient was not consuming any drugs or medication. Follow up imaging studies were carried out over the next 12 months and were still negative (Table 1). Genetic testing for pheochromocytoma was also performed including examination for mutations in ret proto-oncogene (RET), succinate dehydrogenase complex, subunit B (SDHB), von Hippel-Lindau tumor suppressor gene (VHL), which were also negative. In parallel to the medical workup, he was followed by medical psychiatry for his depression, anxiety and physical complaints. Two months after his initial presentation, the antidepressant Citalopram was prescribed, but the patient was poorly adherent and did not take the medication. Treatment with Fluoxetine was initiated seven months post presentation, with better adherence, and titrated up to 30 mg daily. He also underwent occupational and physical therapy. This led to some improvement in his mood, anxiety, somatic complaints and functioning, and a concomitant, progressive drop in his catecholamine levels, which on last measurement had normalized (Table 1).