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Oral examinations have become more standardized over recent years. Traditionally a small number of raters were used for this type of examination. Past studies suggested that more raters should improve reliability. We compared the results of a multi-station structured oral examination using two different rater models, those based in a station, (station-specific raters), and those who follow a candidate throughout the entire examination, (candidate-specific raters).Two station-specific and two candidate-specific raters simultaneously evaluated internal medicine residents' performance at each station. No significant differences were found in examination scores. Reliability was higher for the candidate-specific raters. Inter-rater reliability, internal consistency and a study of station inter-correlations suggested that a halo effect may be present for candidates examined by candidate-specific raters. This study suggests that although the model of candidate-specific raters was more reliable than the model of station-specific raters for the overall examination, the presence of a halo effect may influence individual examination outcomes.

Objective: To report a case of atazanavir-associated choledocholithiasis in an HIV-infected individual., Case Summary: A 47-year-old treatment-naïve HIV-positive African female presented to the emergency department with a 3-day history of right epigastric pain. Six weeks prior to this episode, she began antiretroviral therapy with a regimen consisting of atazanavir 400 mg and abacavir/lamivudine 600/300 mg once daily. Alanine aminotransferase (766 U/L), aspartate aminotransferase (876 U/L), gamma-glutamyltransferase (588 U/L), alkaline phosphatase (348 U/L), and total bilirubin (3.9 mg/dL) levels were elevated. Abdominal ultrasound revealed obstructive choledocholithiasis as well as intra- and extrahepatic biliary dilatation. She underwent a laparoscopic cholecystectomy, which revealed approximately 50 small calculi present in the gallbladder. Since previous ultrasounds had also shown gallstones, an analysis of the extracted calculi was performed to determine the possible association with atazanavir use; low amounts of atazanavir were detected., Discussion: Atazanavir is an inhibitor of the bilirubin-conjugating enzyme UGT1A1 and has been frequently linked to the occurrence of hyperbilirubinemia without complications. This individual experienced hyperbilirubinemia that peaked at hospital presentation after she developed choledocholithiasis and secondary acute hepatitis. Analysis of the extracted gallstones revealed that smaller stones contained a higher content of atazanavir than larger stones, which suggests that atazanavir precipitation may play a role in cholelithiasis, although the mechanism remains unknown. The low yield of atazanavir may be explained by the short, 6-week duration of drug exposure as well as the lack of assay for metabolites. The Naranjo probability scale implicated choledocholithiasis as a possible atazanavir-associated adverse event. This report provides the first published evidence that even short-term use of atazanavir may lead to hyperbilirubinemia with choledocholithiasis and secondary acute hepatitis in HIV-infected adults., Conclusions: Atazanavir should be considered a possible contributor in the development of cholelithiasis or choledocholithiasis, and people with HIV should receive adequate counseling in the recognition of symptoms associated with gallstones. The exact incidence and mechanism still need to be elucidated.

Objective: The in-training evaluation report (ITER) is widely used to assess clinical skills, but has limited validity and reliability. The purpose of our study was to assess the feasibility, validity, reliability, and effect on feedback of using daily evaluation forms to evaluate residents in ambulatory rheumatology clinics., Methods: An evaluation form was developed based on the Royal College of Physicians and Surgeons of Canada CanMEDS roles. There were 12 evaluation items including overall clinical competence. They were rated on a 5-point scale from unsatisfactory to outstanding. All internal medicine residents rotating on rheumatology were strongly encouraged to provide the form to their preceptor at the end of each clinic. A questionnaire was administered to residents and faculty., Results: Seventy-three internal medicine residents completed a 1-month rotation at University of Ottawa (n=26) and McMaster University (n=47). Faculty members completed a total of 637 evaluation forms. The number of evaluation forms ranged from 2 to 16 (mean 8.73) per resident. At an average of 8.73 forms per resident the reliability was 0.71 for the composite score. Fourteen forms would be required for a reliability of 0.8. The correlation between the objective structured clinical examination scores and the forms was 0.48 (p=not significant). Faculty and residents reported increased feedback following implementation of the forms., Conclusion: The use of daily evaluation forms is feasible and provides very good reliability. Use of the evaluation forms increases feedback to residents on their performance. The forms were well received by faculty and residents.

Context: The objective structured clinical examination (OSCE) requires the use of standardised patients (SPs). Recruitment of SPs can be challenging and factors assumed to be neutral may vary between SPs. On stations that are considered gender-neutral, either male or female SPs may be used. This may lead to an increase in measurement error. Prior studies on SP gender have often confounded gender with case., Objective: The objective of this study was to assess whether a variation in SP gender on the same case resulted in a systematic difference in student scores., Methods: At the University of Ottawa, 140 Year 3 medical students participated in a 10-station OSCE. Two physical examination stations were selected for study because they were perceived to be 'gender-neutral'. One station involved the physical examination of the back and the other of the lymphatic system. On each of the study stations, male and female SPs were randomly allocated., Results: There was no difference in mean scores on the back examination station for students with female (6.96/10.00) versus male (7.04/10.00) SPs (P = 0.713). However, scores on the lymphatic system examination station showed a significant difference, favouring students with female (8.30/10.00) versus male (7.41/10.00) SPs (P < 0.001). Results were not dependent on student gender., Conclusions: The gender of the SP may significantly affect student performance in an undergraduate OSCE in a manner that appears to be unrelated to student gender. It would be prudent to use the same SP gender for the same case, even on seemingly gender-neutral stations.

Haverhill fever and rat-bite fever are closely-related syndromes caused by Streptobacillus moniliformis. This infection is characterized by the abrupt onset of fever with rigors, myalgias, headache, polyarthritis, and rash. We report a case of infection with S. moniliformis that manifested as acute polyarthritis with involvement of the spine. To our knowledge, involvement of the spine has not been reported previously with this infection. Diagnosis can be particularly difficult in the absence of fever or obvious exposure to rodents, as in our case. A high degree of awareness is necessary to make the diagnosis of this potentially fatal infection, which is easily treatable.

Introduction: It has previously been reported that a critical pathway for community-acquired pneumonia (CAP) significantly reduces bed days per patient managed but results in no difference in average length of stay, suggesting that discharge criteria were not successfully implemented. The present study sought to identify factors in the timing of discharge not taken into account by discharge criteria., Methods: Patients admitted with CAP and placed on a pneumonia critical pathway were studied. Patients' functional and cognitive status were evaluated using the Barthel Index, Hierarchical Assessment of Balance and Mobility (HABAM) and the Mini-Mental Status Examination. Once discharge criteria were met, the patient, a family member and the treating physician were interviewed to identify other factors contributing to length of stay., Results: Thirty-one patients were enrolled in the study; 12 were discharged when they met discharge criteria and 19 stayed in hospital longer. There were no differences between patients discharged at stability versus those with an increased length of stay in terms of demographics, pneumonia severity score, functional or cognitive status at discharge using the Barthel Index (87.3+/-11.1 versus 83.8+/-8.6, respectively; P=0.46) and MMSE (27.1+/-1.1 versus 27.3+/-1.1, respectively; P=0.64); however, there was a significant difference in HABAM score at the time clinical stability was reached (22.6+/-1.3 versus 17.4+/-3.5, respectively; P=0.03), which correlated with physician and family assessments of patients' readiness for discharge., Conclusions: HABAM may be a useful tool to identify patients at risk of remaining in hospital after objective discharge criteria are met. Additional resources may be targeted at these patients to reduce length of stay in CAP.

Background: The Medical Council of Canada (MCC) administers an objective structured clinical examination for licensure. Traditionally, physician examiners (PE) have evaluated these examinees. Recruitment of physicians is becoming more difficult. Determining if alternate scorers can be used is of increasing importance., Method: In 2003, the MCC ran a study using trained assessors (TA) simultaneously with PEs. Four examination centers and three history-taking stations were selected. Health care workers were recruited as the TAs., Results: A 3x2x4 mixed analyses of variance indicated no significant difference between scorers (F1,462=.01, p=.94). There were significant interaction effects, which were, localized to site 1/station 3, site 3/station 2, and site 4/station1. Pass/fail decisions would have misclassified 14.4-25.01% of examinees., Conclusion: Trained assessors may be a valid alternative to PE for completing checklists in history-taking stations, but their role in completing global ratings is not supported by this study.

Recruitment of physician examiners for an objective structured clinical examination (OSCE) can be difficult. The following study will explore reasons why physicians volunteer their time to be OSCE examiners. A questionnaire was collected from 110 examiners including a fourth year formative student OSCE (SO) (n=49), formative internal medicine OSCE (IM) (n=21) and the Medical Council of Canada Qualifying Exam Part II (MCCQE II) (n=40). A 5-point Likert scale was used. Statements with high mean ratings overall included: enjoy being an examiner (4.05), gain insights into learners' skills and knowledge (4.27), and examine out of a sense of duty (4.10). The MCC participants produced higher ratings (p<0.05). Overall, OSCE examiners volunteer their time because they enjoy the experience, feel a sense of duty and gain insight into learners' skills and knowledge. The MCC examiners appear to value the experience more. The ability to provide feedback and the provision of CME credits were not significant factors for increasing examiner satisfaction.

Objective: To compare community-acquired pneumonia (CAP) in hospitalized human immunodeficiency virus (HIV)-infected patients with that in hospitalized non-HIV-infected patients by assessing presenting characteristics, etiology and outcomes., Design: Retrospective chart review., Setting: A tertiary care centre in Halifax, Nova Scotia., Population Studied: Thirty-two HIV-infected patients requiring hospitalization for treatment of CAP were identified from September 1991 to October 1993 and compared with 33 age-matched non-HIV-infected patients who presented with pneumonia during the same period., Main Results: The two populations were comparable in age, sex and race. Fifty per cent of the HIV-infected and 20.8% of the non-HIV-infected patients had had a previous episode of pneumonia. Pneumocystis carinii pneumonia (PCP) accounted for 16 of the 32 episodes of CAP in the HIV-infected patients, while none of the non-HIV-infected patients had PCP. Pneumonia secondary to Streptococcus pneumoniae was more common in the non-HIV-infected patients (five versus one, P=0.02). Vital signs and initial PO(2) did not differ between the two groups. White blood cell count was lower at admission for the HIV population (5.7×10(9)/L versus 12.7×10(9)/L, P=0.003). The HIV patients were more likely to undergo bronchoscopy (27.7% versus 0%, P<0.001). The length of stay in hospital, transfer to the intensive care unit and necessity for intubation were the same for both groups. The in-hospital mortality for HIV-infected patients was eight of 32 (25%) while for the non-HIV-infected patients it was none of 33 (P=0.002)., Conclusions: Patients with HIV infection who present with CAP are more likely to have PCP, to have had a past episode of pneumonia and to die while in hospital than age- and sex-matched non-HIV-infected patients with CAP.