Postgraduate Medicine Research Articles

The views of key stakeholders in Zimbabwe on the introduction of postgraduate family medicine training: A qualitative study.

BackgroundStrengthening primary health care (PHC) is a priority for all effective health systems, and family physicians are seen as a key member of the PHC team. Zimbabwe has joined a number of African countries that are seriously considering the introduction of postgraduate family medicine training. Implementation of training, however, has not yet happened.AimTo explore the views of key stakeholders on the introduction of postgraduate family medicine training.SettingKey academic, governmental and professional stakeholders in Zimbabwean health and higher education systems.MethodTwelve semi-structured interviews were conducted with purposively selected key stakeholders. Data were recorded, transcribed and analysed using the framework method.ResultsAnticipated benefits: More effective functioning of PHC and district health services with reduced referrals, improved access to more comprehensive services and improved clinical outcomes. Opportunities: International trend towards family medicine training, government support, availability of a small group of local trainers, need to revise PHC policy. Anticipated barriers: Family medicine is unattractive as a career choice because it is largely unknown to newly qualified doctors and may not be recognised in private sector. There is concern that advocacy is mainly coming from the private sector. Threats: Economic conditions, poor remuneration, lack of funding for resources and new initiatives, resistance from other specialists in private sector.ConclusionStakeholders anticipated significant benefits from the introduction of family medicine training and identified a number of opportunities that support this, but also recognised the existence of major barriers and threats to successful implementation.

Because Life Is Open Book: An Open Internet Family Medicine Clerkship Exam.

A core principle of family medicine is information mastery, or application of principles of evidence-based medicine in clinical practice. While information mastery teaching and assessment are beginning to permeate postgraduate family medicine training programs, and while exciting literature on new open resource assessment methods is emerging, there are no prior descriptions of examinations that specifically assess medical students' information mastery competency. To test information mastery competency, a novel final exam for the family medicine clerkship was developed, implemented, and evaluated. During the timed exam, the competency-based information mastery assessment (IMA) requires students to look up evidence-based information using web resources to answer case-based questions. Exam feasibility was tested with pilot examinees whose reactions were gauged. Student performance on the traditional closed book knowledge assessment (KA) was compared with performance on the open internet IMA. Exam performance was compared with preceptor ratings of students' clinical performance. Low performers were further analyzed for preceptors' ratings of specific student skills in information mastery and self-directed learning. An open internet IMA testing knowledge application and information mastery skills is not only feasible but can also be educational. Student performance scores on the open internet IMA do not differ from scores on the closed book KA. Students describe many positive features of this open internet IMA. Student performance on the competency-based IMA correlates with clinical ratings by preceptors and with preceptors' judgment of information mastery skills. A novel approach to assessment in family medicine clerkships may be used to assess student competency in information mastery. Further research is needed for enhanced exam validation.

Reaching national consensus on the core clinical skill outcomes for family medicine postgraduate training programmes in South Africa.

BackgroundFamily physicians play a significant role in the district health system and need to be equipped with a broad range of clinical skills in order to meet the needs and expectations of the communities they serve. A previous study in 2007 reached national consensus on the clinical skills that should be taught in postgraduate family medicine training prior to the introduction of the new speciality. Since then, family physicians have been trained, employed and have gained experience of working in the district health services. The national Education and Training Committee of the South African Academy of Family Physicians, therefore, requested a review of the national consensus on clinical skills for family medicine training.MethodsA Delphi technique was used to reach national consensus in a panel of 17 experts: family physicians responsible for training, experienced family physicians in practice and managers responsible for employing family physicians.ResultsConsensus was reached on 242 skills from which the panel decided on 211 core skills, 28 elective skills and 3 skills to be deleted from the previous list. The panel was unable to reach consensus on 11 skills.ConclusionThe findings will guide training programmes on the skills to be addressed and ensure consistency across training programmes nationally. The consensus will also guide formative assessment as documented in the national portfolio of learning and summative assessment in the national exit examination. The consensus will be of interest to other countries in the region where training programmes in family medicine are developing.

Simulation in Canadian postgraduate emergency medicine training - a national survey.

Simulation-based education (SBE) is an important training strategy in emergency medicine (EM) postgraduate programs. This study sought to characterize the use of simulation in FRCPC-EM residency programs across Canada. A national survey was administered to residents and knowledgeable program representatives (PRs) at all Canadian FRCPC-EM programs. Survey question themes included simulation program characteristics, the frequency of resident participation, the location and administration of SBE, institutional barriers, interprofessional involvement, content, assessment strategies, and attitudes about SBE. Resident and PR response rates were 63% (203/321) and 100% (16/16), respectively. Residents reported a median of 20 (range 0-150) hours of annual simulation training, with 52% of residents indicating that the time dedicated to simulation training met their needs. PRs reported the frequency of SBE sessions ranging from weekly to every 6 months, with 15 (94%) programs having an established simulation curriculum. Two (13%) of the programs used simulation for resident assessment, although 15 (94%) of PRs indicated that they would be comfortable with simulation-based assessment. The most common PR-identified barriers to administering simulation were a lack of protected faculty time (75%) and a lack of faculty experience with simulation (56%). Interprofessional involvement in simulation was strongly valued by both residents and PRs. SBE is frequently used by Canadian FRCPC-EM residency programs. However, there exists considerable variability in the structure, frequency, and timing of simulation-based activities. As programs transition to competency-based medical education, national organizations and collaborations should consider the variability in how SBE is administered.

Examining critical factors affecting graduate retention from an emergency medicine training program in Addis Ababa, Ethiopia: a qualitative study of stakeholder perspectives

In Ethiopia, improvement and innovation of the emergency care system is hindered by lack of specialist doctors trained in emergency medicine, underdeveloped emergency care infrastructure, and resource limitations. Our aim was to examine the critical factors affecting retention of graduates from the Addis Ababa University (AAU) post-graduate emergency medicine (EM) training program within the Ethiopian health care system. One post-graduate trainee and one program manager from the AAU and the University of Toronto (UT) partnership conducted qualitative interviews with current AAU EM residents and stakeholders in Ethiopian EM. Qualitative inductive thematic analysis was performed. Resident and stakeholder participants identified critical factors in three domains: the individual condition, the occupational environment, and the national context. Within each domain, priority themes emerged from the responses, including the importance of career satisfaction over the career continuum (individual condition), the opportunity to be involved in the developing EM program and challenges associated with resource, economic, and employment constraints (occupational environment), and perceptions regarding the state of awareness of EM and the capacity for change at the societal level (national context). This work underscores the need to continue to address multiple systemic and cultural issues within the Ethiopian health care landscape in order to address EM graduate retention. It also highlights the potential success of a retention strategy focused on the career ambitions of keen EM doctors.

Construction of Multiple Choice Questions Before and After An Educational Intervention

Khesar Gyalpo University of Medical Sciences of Bhutan, established in 2014, has ushered in a new era in medical education in Bhutan. Multiple Choice Questions are a common means of written assessment in medical education. This was a quasi-experimental study conducted at the Faculty of Postgraduate Medicine, KGUMSB, Thimphu in December 2016. A total of 8 MCQs were prepared by four teaching faculties from different fields who had no prior training on construction of MCQs. It was delivered to a group of 16 randomly selected intern doctors. A 2 hours long workshop on construction of MCQs was conducted. After the workshop, the same MCQs were modified according to standard guidelines on developing MCQs and were tested in the same group of intern doctors. An analysis on the performance, difficulty factor, discrimination index and distractor analysis was done on the two sets of MCQs using Microsoft Excel and SPSS 20.0. For the pre- and post-workshop questions respectively, the pass percentage was 69.8% (11) and 81.3% (13), difficulty factor was 0.51 and 0.53, discrimination index was 0.59 and 0.47, distractor effectiveness was 83.3% and 74.9%. The workshop on MCQ development apparently seemed highly valuable and effective in changing the learning and performances of medical educators in the development of MCQs.

A Questionnaire-Based Survey of Physical Medicine and Rehabilitation Residency Training in Pakistan.

Pakistan is one of the three countries in South East Asia that has an active postgraduate physical medicine and rehabilitation (PM&R) training program. College of Physicians and Surgeons Pakistan (CPSP) offers a four-year structured training program in PM&R. It consists of clinical teaching, lectures, rotations in other specialties, and writing a research dissertation.The aim of this survey was to provide an objective analysis of the current PM&R training program, including the facilities available for training, the participation of residents in academic activities, and their participation in different PM&R procedures.Hospital ethics committee approval was obtained. The questionnaire had sections on informed consent; basic demographics; the different components of residency training; and self-assessement of competence in different procedural skills. It was approved by the dean of PM&R at CPSP. There are six accredited training centers in Pakistan. Twelve residents are undergoing residency training at four different centers (Dec 2015). Key persons were nominated at each center to facilitate data collection. All residents (100% response rate) completed the survey. Almost all had read the CPSP training manual. Most had submitted the research dissertation. Training facilities varied across different centers, with the military center being the best equipped. The self-assessed competence of residents in different PM&R procedures varied among different centers, but overall it conformed to the competency levels specified in the training manual.Overall PM&R residency training in Pakistan is satisfactory, but there is a need to strengthen the weak areas and standardize the training across all centers in the country.

Integration of a Problem-based Learning Module into a Post-graduate Pain Medicine Education Program

Integration of a Problem-based Learning Module into a Post-graduate Pain Medicine Education Program

Objective Structured Clinical Examination (OSCE) in Psychiatry Education: A Review of Its Role in Competency-Based Assessment.

Over the last two decades, Objective Structured Clinical Examination (OSCE) has become an increasingly important part of psychiatry education and assessment in the Australian context. A reappraisal of the evidence base regarding the use of OSCE in psychiatry is therefore timely. This paper reviews the literature regarding the use of OSCE as an assessment tool in both undergraduate and postgraduate psychiatry training settings. Suitable articles were identified using the search terms 'psychiatry AND OSCE' in the ERIC (educational) and PubMed (healthcare) databases and grouped according to their predominant focus: (1) the validity of OSCEs in psychiatry; (2) candidate preparation and other factors impacting on performance; and (3) special topics. The literature suggests that the OSCE has been widely adopted in psychiatry education, as a valid and reliable method of assessing psychiatric competencies that is acceptable to both learners and teachers alike. The limited evidence base regarding its validity for postgraduate psychiatry examinations suggests that more research is needed in this domain. Despite any shortcomings, OSCEs are currently ubiquitous in all areas of undergraduate and postgraduate medicine and proposing a better alternative for competency-based assessment is difficult. A critical question is whether OSCE is sufficient on its own to assess high-level consultancy skills, and aspects of professionalism and ethical practice, that are essential for effective specialist practice, or whether it needs to be supplemented by additional testing modalities.

Confidence in Procedural Skills before and after a Two-Year Master's Programme in Family Medicine in Gezira State, Sudan.

Many postgraduate family medicine training programmes have been developed to meet the worldwide dire need for practicing family physicians. This study was conducted in Gezira state of Sudan in a “before-and-after” design in the period of 2010–2012 with the aim to assess improvements in candidates' confidence in performing certain clinical skills. A self-evaluation questionnaire was used with a five-grade scale (1–5) to assess candidates' confidence in performing 46 clinical skills. A group of 108 participants responded for both the “before” and the “after” questionnaire: the response rate was 91% (before) and 90% (after). In general, a positive progress trend was detected. The mean skill value for all skills was 3.23 (before) and 3.93 (after) with a mean increase of 21.7% (P < 0.001). Male students scored constantly higher than females both before and after completing the master's programme, while females showed a higher percentage in progress. Scores in certain medical disciplines were higher than others. However, disciplines with low scores in the beginning, such as psychiatry and ophthalmology, showed the highest progress percentage. The results show a significant increase in confidence in performing procedural skills designed in the curriculum of the GFMP master's programme.

Multiple Mini-Interview for Postgraduate Year Residency Recruitment: First Experience in Taiwan

Background: We investigated the effectiveness of the first hospital-held multiple mini-interview for recruitment into a postgraduate residency program in Taiwan. Methods: We conducted a multiple mini-interview to recruit 37 trainees into the postgraduate general medicine residency in January 2017 of the 37 postgraduate year candidates, 28 had interned at our hospital. Between-group correlations among subgroup analyses using multiple comparisons, Chi square test, and the generalized linear model were conducted to test the validity and discrimination of the multiple mini-interview questions. Correlations between multiple mini-interview scores, objective structured clinical examination scores, and clinical practice examinations were conducted and available for 19 applicants who interned at this hospital to test the effectiveness of the multiple mini-interview as a recruiting tool. Results: The multiple mini-interview process exhibited high test discrimination (P<0.001). Whether an intern studied at our hospital or at a different hospital did not affect the performance of the multiple mini-interview. Significant correlations were observed among performance in the multiple mini-interview, all three objective structured clinical examinations, and in four of six clinical practice departments among the 19 candidates who interned at our hospital (P<0.05). Conclusions: The significant correlation of the multiple mini-interviews with clinical performance scores provides powerful support for multiple mini-interview assessment in recruiting residents suitable for clinical work. Continuing to collect data to study the multiple mini-interview program would improve our understanding of it and provide better support for the postgraduate year recruitment program.

Getting It Right the First Time: Defining Regionally Relevant Training Curricula and Provider Core Competencies for Point-of-Care Ultrasound Education on the African Continent

Significant evidence identifies point-of-care ultrasound (PoCUS) as an important diagnostic and therapeutic tool in resource-limited settings. Despite this evidence, local health care providers on the African continent continue to have limited access to and use of ultrasound, even in potentially high-impact fields such as obstetrics and trauma. Dedicated postgraduate emergency medicine residency training programs now exist in 8 countries, yet no current consensus exists in regard to core PoCUS competencies. The current practice of transferring resource-rich PoCUS curricula and delivery methods to resource-limited health systems fails to acknowledge the unique challenges, needs, and disease burdens of recipient systems. As emergency medicine leaders from 8 African countries, we introduce a practical algorithmic approach, based on the local epidemiology and resource constraints, to curriculum development and implementation. We describe an organizational structure composed of nexus learning centers for PoCUS learners and champions on the continent to keep credentialing rigorous and standardized. Finally, we put forth 5 key strategic considerations: to link training programs to hospital systems, to prioritize longitudinal learning models, to share resources to promote health equity, to maximize access, and to develop a regional consensus on training standards and credentialing.

Women in senior post-graduate medicine career roles in the UK: a qualitative study.

ObjectivesThis qualitative study sought to elicit the views, experiences, career journeys and aspirations of women in senior post-graduate medical education roles to identify steps needed to help support career progression.DesignIn-depth semi-structured telephone interviews.SettingUK.ParticipantsPurposive sample of 12 women in a variety of senior leadership roles in post-graduate medical education in the UK.Main outcome measuresSelf reported motivating influences, factors that helped and hindered progress, key branch points, and key educational factors and social support impacting on participants' career in postgraduate medicine.ResultsRespondents often reported that career journeys were serendipitous, rather than planned, formal or well structured. Senior women leaders reported having a high internal locus of control, with very high levels of commitment to the NHS. All reported significant levels of drive, although the majority indicated that they were not ambitious in the sense of a strong drive for money, prestige, recognition or power. They perceived that there was an under-representation of women in senior leadership positions and that high-quality female mentorship was particularly important in redressing this imbalance. Social support, such a spouse or other significant family member, was particularly valued as reaffirming and supporting women’s chosen career ambition. Factors that were considered to have hindered career progression included low self-confidence and self-efficacy, the so-called glass ceiling and perceived self-limiting cultural influences. Factors indirectly linked to gender such as part-time versus working full time were reportedly influential in being overlooked for senior leadership roles. Implications of these findings are discussed in the paper.ConclusionSocial support, mentorship and role modelling are all perceived as highly important in redressing perceived gender imbalances in careers in post-graduate medical education.

Use of WONCA global standards to evaluate family medicine postgraduate education for curriculum development and review in Nepal and Myanmar

Family medicine is an integral part of primary care within health systems. Globally, training programmes exhibit a great degree of variability in content and skill acquisition. While this may in part reflect the needs of a given setting, there exists standard criteria that all family medicine programmes should consider core activities. WONCA has provided an open-access list of standards that their expert community considers essential for family medicine (GP) post-graduate training. Evaluation of developing or existing training programmes using these standards can provide insight into the degree of variability, gaps within programmes and equally as important, gaps within recommendations. In collaboration with the host institution, two family medicine programmes in Nepal and Myanmar were evaluated based on WONCA global standards. The results of the evaluation demonstrated that such a process can allow for critical review of curriculum in various stages of development and evaluation. The implications of reviewing training programmes according to WONCA standards can lead to enhanced training world-wide and standardisation of training for post-graduate family medicine.

Postgraduate training for family medicine in a rural district hospital in South Africa: Appropriateness and sufficiency of theatre procedures as a sentinel indicator.

BackgroundSince 2007, the postgraduate training of family physicians for South African district hospitals has been formalised. This training differs from European and North American programmes as up to 30% of the skills needed rely on district hospital surgical, obstetrics and anaesthetics procedures, particularly in rural areas, as outlined in the national unit standards. The aim of this study was to evaluate the appropriateness and sufficiency of learning opportunities for these skills in a rural district hospital.MethodsA descriptive, cross-sectional study was undertaken of the number and type of procedures performed in theatre for a 1-year period and compared with the required procedural skills stipulated in the national unit standards. Descriptive statistical analyses were used to analyse categorical data.ResultsThree thousand seven hundred and forty-one procedures were performed during the study period. Anaesthesia was the most common procedure, followed by Caesarean section. There were adequate opportunities for teaching most core skills.ConclusionsSufficient and appropriate learning opportunities exist for postgraduate family medicine training in all the core skills performed in a theatre according to the national unit standards.

Bi-cultural, bi-national benchmarking and assessment of clinical reasoning in Obstetrics and Gynaecology

This article was migrated. The article was marked as recommended. Background: The Script Concordance Test (SCT) is being increasingly used in professional development in clinical reasoning (CR) in postgraduate medicine. On-line delivery favours multi-institutional collaboration. Objectives: To establish if: 1) SCT questions developed in the French-speaking University of Montreal were readily adaptable for use in the English-speaking University of Adelaide 2) expert reference panels (ERP) from both institutions could be used interchangeably 3) student cohorts would perform similarly in the same test. Study Design: 82 SCT questions based on 27 clinical cases in Obstetrics and Gynaecology were developed in Montreal and run in a volunteer cohort of year 3 and year 4 medical students (n=154). Local faculty translated all questions, selecting 31 based on 17 clinical cases for use in summative examinations a year 5 student cohort in Adelaide (n=123). Results: Mean (SD) percentage scores using each ERP key were: 74.2 (6.4) versus 73.3 (6.9), p&lt;0.001 for Adelaide students and 72.5 (7.8) versus 70.6 (8.8), p&lt;0.001 for Montreal students. The correlation coefficients were ≥ 0.928 (p&lt;0.001). Conclusions: Student cohorts performed similarly regardless of which ERP key was used. With appropriate editorial control, SCT's can be effectively shared between French and English-speaking institutions located in different hemispheres. Potential advantages include the creation of an international database of assessment items, benchmarking and cost sharing.

Rethinking postgraduate medical education in today's India - a comparison with western systems.

To compare and contrast the medical postgraduate training programme of India with the UK and western universities. We analysed the admission process, curriculum and training requirements during the postgraduate medicine programme. We compared the course requirements and examination process. We …

Rethinking postgraduate medical education in today’s India – a comparison with western systems

To compare and contrast the medical postgraduate training programme of India with the UK and western universities. We analysed the admission process, curriculum and training requirements during the postgraduate medicine programme. We compared the course requirements and examination process. We …

P043: Education innovation: a postgraduate emergency medicine musculoskeletal medicine curriculum

Introduction / Innovation Concept: Musculoskeletal medicine (MSKM) complaints account for a significant portion of emergency room visits. Furthermore, MSKM diagnostic and management skills are poorly taught in undergraduate medicine and emergency medicine (EM). Here, we successfully developed an MSKM curriculum resulting in objectively improved resident acumen. Methods: Curriculum development was achieved by surveying local EM residents on their perceived MSKM deficits, and effective MSK teaching strategies. A literature search was also completed identifying MSKM teaching shortcomings. Finally, orthopaedic surgeons were asked which clinical entities they thought should be emphasized in our curriculum. Curriculum, Tool, or Material: A case-based MSKM curriculum was created. Cases emphasized commonly occurring emergency department presentations, topics that EM practitioners self-identified as requiring further teaching, commonly missed problems at first presentation, and high-risk cases if mismanaged. Curriculum implementation consisted of three, half-day, workshops. Workshops included didactic lectures, MSKM physical exam practice, and MSKM cases. MSKM cases required resident history taking and physical exam practice, radiography interpretation, and management plan formulation. Objective assessments of resident MSKM knowledge and skill were given to the learners before and after the workshops. Survey questions were grouped into 3 categories: MSK assessment, investigation, and management. Questions were scored on a 5-point Likert scale, ranging from “not at all confident” to “very confident”. A Wilcoxon Signed Rank Test indicated statistically significant improvement in learner confidence within all three domains after the first workshop (n=19 learners; assessment: p&lt;0.001, investigation: p&lt;0.001, management: p&lt;0.001), and after the second workshop (n=24 learners; assessment: p&lt;0.001, investigation: p&lt;0.001, management: p&lt;0.001). Conclusion: We successfully incorporated MSKM teaching into our academic curriculum based on previously identified weaknesses, resulting in improved resident MSKM case management. Further MSKM teaching sessions and evaluations to facilitate knowledge and skill maintenance are currently under development.

LO064: Simulation in Canadian postgraduate emergency medicine training — a national survey

Introduction: Simulation-based medical education (SBME) is an important training strategy in emergency medicine (EM) postgraduate programs yet the extent of its use is variable. This study sought to characterize the use of simulation in FRCP-EM residency programs across Canada. Methods: A national survey was administered to residents (PGY2-5) and program representatives (PR), either a program director or simulation lead at all Canadian FRPC-EM programs. Residents completed either paper or electronic versions of the survey, and PR surveys were conducted by telephone. Results: The resident and PR response rates were 60% (187/310) and 100% (16/16), respectively. All residency programs offer both manikin-based high fidelity and task trainer simulation modalities. Residents reported a median of 20 (range 0-150) hours participating in simulation training annually, spending a mean of 16% of time in situ, 55% in hospital-based simulation laboratories, and 29% in off-site locations. Only 52% of residents indicated that the time dedicated to simulation training met their training needs. All PRs reported having a formal simulation curriculum with a frequency of simulation sessions ranging from weekly to every 6 months. Only 3/16 (19%) of programs linked their simulation curriculum to their core teaching. Only 2/16 programs (13%) used simulation for resident assessment, though 15/16 (93%) PRs indicated they would be comfortable with simulation-based assessment. The most common PR identified barriers to administering simulation by were a lack of protected faculty time (75%) and a lack of faculty experience with simulation (56%). Both PRs and residents identified a desire for more simulation training in neonatal resuscitation, pediatric resuscitation, and obstetrical emergencies. Multidisciplinary involvement in simulations was strongly valued by both residents and PRs, with 76% of residents indicating that they would like greater multidisciplinary involvement. Conclusion: Among Canadian FRCP-EM residency programs, SBME is a frequently used training modality, however, there exists considerable variability in the structure, frequency and timing of simulation exposure for residents. Several common barriers were identified that impact SBME implementation. The transition to competency-based medical education will require a national, standardized approach to SBME that includes a unified strategy for training and assessment.