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Context Teaching effectiveness ratings (TERs) are used to provide feedback to teachers on their performance and to guide decisions on academic promotion. However, exactly how raters make decisions on teaching effectiveness is unclear. Objectives The objectives of this study were to identify variables that medical students appraise when rating the effectiveness of a classroom teacher, and to explore whether the relationships among these variables and TERs are modified by the physical attractiveness of the teacher. Methods We asked 48 Year 1 medical students to listen to 2-minute audio clips of 10 teachers and to describe their impressions of these teachers and rate their teaching effectiveness. During each clip, we displayed either an attractive or an unattractive photograph of an unrelated third party. We used qualitative analysis followed by factor analysis to identify the principal components of teaching effectiveness, and multiple linear regression to study the associations among these components, type of photograph displayed, and TER. Results We identified two principal components of teaching effectiveness: charisma and intellect. There was no association between rating of intellect and TER. Rating of charisma and the display of an attractive photograph were both positively associated with TER and a significant interaction between these two variables was apparent (p

Ultrasonography is increasingly used for teaching anatomy and physical examination skills but its effect on cognitive load is unknown. This study aimed to determine ultrasound's perceived utility for learning, and to investigate the effect of cognitive load on its perceived utility. Consenting first-year medical students (n = 137) completed ultrasound training that includes a didactic component and four ultrasound-guided anatomy and physical examination teaching sessions. Learners then completed a survey on comfort with physical examination techniques (three items; alpha = 0.77), perceived utility of ultrasound in learning (two items; alpha = 0.89), and cognitive load on ultrasound use [measured with a validated nine-point scale (10 items; alpha = 0.88)]. Learners found ultrasound useful for learning for both anatomy and physical examination (mean 4.2 ± 0.9 and 4.4 ± 0.8, respectively; where 1 = very useless and 5 = very useful). Principal components analysis on the cognitive load survey revealed two factors, “image interpretation” and “basic knobology,” which accounted for 60.3% of total variance. Weighted factor scores were not associated with perceived utility in learning anatomy (beta = 0.01, P = 0.62 for “image interpretation” and beta = −0.04, P = 0.33 for “basic knobology”). However, factor score on “knobology” was inversely associated with perceived utility for learning physical examination (beta = −0.06; P = 0.03). While a basic introduction to ultrasound may suffice for teaching anatomy, more training may be required for teaching physical examination. Prior to teaching physical examination skills with ultrasonography, we recommend ensuring that learners have sufficient knobology skills. Anat Sci Educ 8: 197–204. © 2014 American Association of Anatomists.

Using heuristics offers several cognitive advantages, such as increased speed and reduced effort when making decisions, in addition to allowing us to make decision in situations where missing data do not allow for formal reasoning. But the traditional view of heuristics is that they trade accuracy for efficiency. Here the authors discuss sources of bias in the literature implicating the use of heuristics in diagnostic error and highlight the fact that there are also data suggesting that under certain circumstances using heuristics may lead to better decisions that formal analysis. They suggest that diagnostic error is frequently misattributed to the use of heuristics and propose an alternative view whereby content knowledge is the root cause of diagnostic performance and heuristics lie on the causal pathway between knowledge and diagnostic error or success.

Background Observational studies suggest that emotions experienced during simulation training may affect cognitive load and learning outcomes. The objective of this study was to manipulate emotions during simulation training and assess the impact on cognitive load and learning. Methods In this prospective randomized trial, 116 final-year medical students received training in a simulated scenario of a 70-year-old woman presenting with reduced consciousness due to aminosalicylic acid ingestion. Training groups were randomly allocated to one of two endings for the scenario: The patient was transferred to another service, or she experienced a cardiorespiratory arrest and died. Participants rated their emotions and cognitive load after training. Three months later, we evaluated their performance on a simulation Objective Structured Clinical Examination station of a 60-year-old man presenting with reduced consciousness due to ethylene glycol ingestion. Results Emotions tended to be more negative for students in training groups where the simulated patient died. These students also reported a higher cognitive load (mean ± SD, 7.63 ± 0.97 vs 7.25 ± 0.84; P = .03; d = 0.42) and were less likely to be rated as competent to diagnose and manage a patient with reduced consciousness due to toxin ingestion (OR, 0.37; 95% CI, 0.14-0.95; P = 0.04) 3 months later. Conclusions Students exposed to unexpected simulated patient death reported increased cognitive load and had poorer learning outcomes. Educators need to expose learners to negative experiences; therefore, further studies are needed on how best to use negative emotional experiences during simulation training.

Although the clinical clerkship model is based upon sound pedagogy, including theories of social learning and situated learning, studies evaluating clinical performance of residents suggests that this model may not fully meet the learning needs of students. Here our objective was to design a curriculum to bridge the learning gaps of the existing clerkship model and then evaluate the impact of this on performance on clerkship summative evaluations. We followed Kern’s framework to design our curriculum and then compared performance on the clerkship objective structured clinical examination (OSCE), all summative clerkship multiple choice question (MCQ) examinations, and the Medical Council of Canada Qualifying Examination (MCCQE) Part 1 before and after the introduction of our curriculum. In the 2 years following the introduction of our clinical skills curriculum the mean score on the clerkship OSCE was significantly higher than in the 2 years prior to our curriculum [67.12 (5.3) vs. 62.44 (4.93), p < 0.001, d = 0.91]. With the exception of the surgical clerkship MCQ, performance on all clerkship summative MCQ examinations and MCCQE Part 1 was significantly higher following the introduction of our curriculum. In this study we found a significant improvement in the performance on clerks on summative evaluations of knowledge and clinical skills following the introduction of our clinical skills curriculum. Given the unpredictable nature of clinical rotations, the clerkship will always be a risk of failing to deliver the intended curriculum—so medical schools should continue to explore and evaluate ways of changing the delivery of clerkship training to improve learning outcomes.

Purpose Prior studies suggest that students on a longitudinal integrated clerkship (LIC) have comparable academic performance to those on a rotationbased clerkship (RBC); however, most of these studies did not adjust for preclerkship academic performance. The objective of this study was to compare the academic performance of LIC and RBC students matched on prior academic performance over a three-year period. Method Each LIC student in the University of Calgary classes of 2009, 2010, and 2011 (n = 34) was matched with four RBC students (n = 136) of similar prior academic performance. Knowledge and clinical skills performance between the streams was compared. Knowledge was evaluated by internal summative examinations and the Medical Council of Canada Part 1 licensing exam. Clinical skills were evaluated via intraining evaluation report (ITERs) and performance on the clerkship objective structured clinical examination (OSCE). Meta-analysis was used to compare knowledge evaluations and clinical performance for all core clerkship disciplines, and pooled effect sizes from the fixed-effect models were reported. Results

The longitudinal integrated clerkship (LIC) model has recently become a popular educational model for training clinical clerks. LICs permit students to train in multiple disciplines concurrently and typically in rural practice sites. Because little is known about how graduates of LIC programs fare in residency, the purpose of this study was to compare the clinical performance of residents who graduated from rural longitudinal integrated and urban rotation-based clerkships on the Medical Council of Canada Qualifying Exam Part ll (MCCQE Part ll) taken 16 months into residency. Participants included medical school graduates from the classes of 2009, 2010 and 2011 at the University of Calgary. Each of the 34 LIC students were prospectively matched (first on Medical Skills ll course performance, then grade point average) with 4 students from the traditional rotation-based (RB) stream to serve as controls (n = 136). A dataset containing 170 graduates was forwarded to the Medical Council of Canada (MCC) who subsequently supplied MCCQE Part ll pass/ fail status and total score for each resident, and returned the dataset for our analysis. Data were analyzed using chi-square and analysis of variance. The final dataset for analysis consisted of 30 (88%) LIC graduates and 115 (85%) RB graduates. Analysis revealed a similar MCCQE Part ll pass rate for LIC (28/30; 93.3%) and RB (107/115; 93.0%) graduates, p > 0.05. The MCCQE Part ll mean total score for the LIC graduates (M = 527.4; SD = 64.3) did not differ from the mean total score (M = 529.9; SD = 61.4) reported by the RB graduates, F = 0.04, p = 0.85. Completing the majority of clerkship in a rural community over an extended period allowed LIC graduates to perform as well as their peers on a measure of clinical skills taken 16 months into residency.

BACKGROUND: Although workplace workload assessments exist in different fields, an endoscopy-specific workload assessment tool is lacking.OBJECTIVE: To validate such a workload tool and use it to map the progression of novice trainees in gastroenterology in performing their first endoscopies.METHODS: The National Aeronautics and Space Administration Task Load Index (NASA-TLX) workload assessment tool was completed by eight novice trainees in gastroenterology and 10 practicing gastroenterologists/surgeons. An exploratory factor analysis was performed to construct a streamlined endoscopy-specific task load index, which was subsequently validated. The ‘Endoscopy Task Load Index’ was used to monitor progression of trainee exertion and self-assessed performance over their first 40 procedures.RESULTS: From the factor analysis of the NASA-TLX, two principal components emerged: a measure of exertion and a measure of self-efficacy. These items became the components of the newly validated Endoscopy Task Load Index. There was a steady decline in self-perceived exertion over the training period, which was more rapid for gastroscopy than colonoscopy. The self-efficacy scores for gastroscopy rapidly increased over the first few procedures, reaching a plateau after this period of time. For colonoscopy, there was a progressive increase in reported self-efficacy over the first three quartiles of procedures, followed by a drop in self-efficacy scores over the final quartile.DISCUSSION: The present study validated an Endoscopy Task Load Index that can be completed in

Background Family-centered bedside rounds (family-centered rounds) enable learning and clinical care to occur simultaneously and offer benefits to patients, health care providers, and multiple levels of learners. Objective We used a qualitative approach to understand the dimensions of successful (ie, educationally positive) family-centered rounds from the perspective of attending physicians and residents. Methods We studied rounds in a tertiary academic hospital affiliated with the University of Calgary. Data were collected from 7 focus groups of pediatrics residents and attendings and were analyzed using grounded theory. Results Attending pediatricians and residents described rounds along a spectrum from successful and highly educational to unsuccessful and of low educational value. Perceptions of residents and attendings were influenced by how well the environment, educational priorities, and competing priorities were managed. Effectiveness of the manager was the core variable for successful rounds led by persons who could develop predictable rounds and minimize learner vulnerability. Conclusions Success of family-centered rounds in teaching settings depended on making the education and patient care aims of rounds explicit to residents and attending faculty. The role of the manager in leading rounds also needs to be made explicit.

As medical trainees gain clinical experience, they increasingly form diagnoses based on their association with predisposing conditions and clinical features rather than pathophysiological explanations. Knowledge of these associations is housed as scripts in long-term memory, and data from the expertise literature imply that expert performance is largely explained by experts possessing more accurate scripts. In rotation-based clerkships, students typically spend a short period of time involved in the care of patients and are frequently deprived of the opportunity to observe the evolution and resolution of illness and the correct association between predisposing conditions, clinical features, and final diagnosis that is required for accurate script formation. Thanks to the introduction of an electronic health record (EHR), students now have the opportunity to track former patients until the final diagnosis and response to treatment is known. Although former patients are unlikely to benefit from being tracked by medical students, this type of learning experience may help students form more accurate scripts and, thus, improve their diagnostic performance on subsequent patients. But, because the purpose of EHRs is to improve clinical care of patients, is it ethically acceptable to allow students no longer involved in the care of patients to use these data solely for the purposes of learning? In this Commentary, the authors highlight the potential for ethical conflict whenever clinical care and teaching mingle, and discuss how these competing interests can still be balanced in the face of advancing technology by applying universal ethical principles and following the advice of Hippocrates.

Patient care rounds are a key mechanism by which healthcare providers communicate and make patient care decisions in the ICU but no synthesis of best practices for rounds currently exists. Therefore, we systematically reviewed the evidence for facilitators and barriers to patient care rounds in the ICU.Search of Medline, Embase, CINAHL, PubMed, and the Cochrane library through September 21, 2012.Original, peer-reviewed research studies (no methodological restrictions) were selected, which described current practices, facilitators, or barriers to healthcare provider rounding in the ICU.Two authors with methodological and content expertise independently abstracted data using a prespecified abstraction tool.The literature search identified 7,373 citations. Reviews of abstracts led to the retrieval of 136 full text articles for assessment; 43 articles in three languages (English, German, Spanish) were selected for review. Of these, 13 were ethnographic studies and 15 uncontrolled before-after studies. Six studies used control groups, including one cross-over randomized, one time-series, three cohort, and one controlled before-after study. A total of 13 facilitators and 9 barriers to patient care rounds were identified through a narrative and meta-synthesis of included studies. Identified facilitators suggest that the quality of rounds is improved when conducted by a multidisciplinary group of providers, with explicitly defined roles, using a standardized structure and goal-oriented approach that includes a best practices checklist. Barriers to quality patient care rounds include poor information retrieval and documentation, interruptions, long rounding times, and allied healthcare provider perceptions of not being valued by rounding physicians.Although the evidence base for best practices of patient care rounds in the ICU is limited, several practical and low-risk practices can be considered for implementation.

Background: Ultrasonography is increasingly used for teaching physical examination in medical schools. This study seeks the opinions of educators as to which physical examinations would be most enhanced by the addition of ultrasonography. We also asked when ultrasound-aided physical examination teaching could have deleterious effects if used outside its intended scope. Methods: All of the educators from the University of Calgary Master Teacher Program were invited to complete a 22-item paper-based survey. Survey items were generated independently by two investigators, with input from an expert panel (N = 5). Results: Of the 36 educators, 27 (75%) completed the survey. Examinations identified to be potentially most useful included: measuring the size of the abdominal aorta, identifying the presence/absence of ascites, identifying the presence/absence of pleural effusions, and measuring the size of the bladder. Examinations thought to be potentially most harmful included: identifying the presence/absence of intrauterine pregnancy, measuring the size of the abdominal aorta, and identifying the presence/absence of pericardial effusion. Conclusions: Examinations that are potentially the most useful may also be potentially the most harmful. When initiating an ultrasound curriculum for physical examinations, educators should weigh the risks and benefits of examinations chosen.

Although simulation training improves post-training performance, it is unclear how well performance soon after simulation training predicts longer term outcomes (i.e., learning). Here our objective was to assess the predictive value of performance 1 h post-training of performance 6 weeks later. We trained 84 first year medical students a simulated case of chest pain due to aortic stenosis. They then received training on a case of acute onset dyspnea due to pulmonary embolism, after which we evaluated diagnostic performance on their trained murmur followed by novel murmur. We repeated the evaluation of diagnostic performance on the same murmurs 6 weeks later. One hour post-training 88.1 % of students identified the training murmur, compared to 60.7 % for the novel murmur. Six weeks after training the corresponding results were 89.3 and 65.5 %, respectively (p < 0.0001 for both time periods). The probability of students diagnosing their training murmur 6 weeks post-training if they diagnosed this after 1 h (positive predictive value) was 0.89 [0.87, 0.93], and the probability of misdiagnosing their trained murmur 6 weeks post-training if they misdiagnosed this after 1 h (negative predictive value) was 0.10 [0.01, 0.40]. The corresponding positive and negative predictive values for the novel murmur were 0.69 [0.55, 0.80] and 0.39 [0.24, 0.57], respectively. Students who successfully diagnosed a cardiac murmur 1 h after simulation training were very likely to recognize the same murmur 6 weeks later, suggesting that we can use performance 1 h post-training as a learning outcome.

Prior studies have shown a correlation between the grades students receive and how they rate their teacher in the classroom. In this study, the authors probe this association on clinical rotations and explore potential mechanisms. All In-Training Evaluation Reports (ITERs) for students on mandatory clerkship rotations from April 1, 2013 to January 31, 2015 were matched with the corresponding student’s rating of their teacher (SRT). The date and time that ITERs and SRTs were submitted was used to divide SRTs into those submitted before versus after the corresponding ITER was submitted. Multilevel, mixed effects linear regression was used to examine the association between SRT, ITER rating, and whether the ITER was submitted before or after SRT. Of 2373 paired evaluations, 1098 (46.3%) SRT were submitted before the teacher had submitted the ITER. There was a significant interaction between explanatory variables: when ITER ratings had not yet been submitted, the regression coefficient for this association was 0.25 (95% confidence interval [0.17, 0.33], p

Despite the fact that the length of medical school training has remained stable for many years, the expectations of graduating medical students (and the schools that train them) continue to increase. In this Reflection, the authors discuss motives for educational inflation and suggest that these are likely innocent, well-intentioned, and subconscious-and include both a propensity to increase expectations of ourselves and others over time, and a reluctance to reduce training content and expectations. They then discuss potential risks of educational inflation, including reduced emphasis on core knowledge and clinical skills, and adverse effects on the emotional, psychological, and financial wellbeing of students. While acknowledging the need to change curricula to improve learning and clinical outcomes, the authors proffer that it is naive to assume that we can inflate educational expectations at no additional cost. They suggest that before implementing and/or mandating change, we should consider of all the costs that medical schools and students might incur, including opportunity costs and the impact on the emotional and financial wellbeing of students. They propose a cost-effectiveness framework for medical education and advocate prioritization of interventions that improve learning outcomes with no additional costs or are cost-saving without adversely impacting learning outcomes. When there is an additional cost for improved learning outcomes or a decline in learning outcomes as a result of cost saving interventions, they suggest careful consideration and justification of this trade-off. And when there are neither improved learning outcomes nor cost savings they recommend resisting the urge to change.

factor analysis to identify the principal components of emotion, and then studied the associations between these components of emotion and cognitive load and diagnostic performance. RESULTS We identified two principal components of emotion, which we felt represented invigoration and tranquillity. Both of these were associated with cognitive load with adjusted regression coefficients of 0.63 (95% confidence interval [CI] 0.28–0.99; p = 0.001) and ) 0.44 (95% CI ) 0.77 to ) 0.10; p = 0.009), respectively. We found a significant negative association between cognitive load and the odds of subsequently identifying the trained murmur (odds ratio 0.27, 95% CI 0.11–0.67; p = 0.004). CONCLUSIONS We found that increased invigoration and reduced tranquillity during simulation training were associated with increased cognitive load, and that the likelihood of correctly identifying a trained murmur declined with increasing cognitive load. Further studies are needed to evaluate the impact on performance of strategies to alter emotion and cognitive load during simulation training.

Although the development of collaborative relationships is considered a requirement for medical education, the functioning of these relationships may be impaired by a well-documented social-psychological phenomenon known as group conformity. The authors hypothesized that students would insert a needle into an incorrect location relative to the patella when performing a knee arthrocentesis if they believed that their peers had also inserted a needle in the same incorrect location. This was a randomized controlled study conducted in 2011 with 60 medical students (24 male; 40.0 %) who were randomly assigned to either using a knee model that had a skin with holes left by peers inserting needles in the wrong location, or a knee with no marks in the skin. Each student's aspiration site was measured with a fibreglass ruler to determine whether it was correctly located within the superior third, 1 cm medial to the patella. The researchers determined that students who used the marked skin were more likely to insert the needle in the incorrect location compared to those who used the clean skin (n = 31, 86.11 vs. n = 14, 58.33 %), Fisher's exact test (1) = 5.93, p < 0.05, Cramer's ϕ = 0.31. This study demonstrates incorrect performance of the knee arthrocentesis procedure in simulation when students use a damaged model, which may be due to conformity. It suggests that further research on the impact of conformity in medical education is warranted.

Summary Background and objectives Despite reporting estimated GFR (eGFR), use of evidence-based interventions in CKD remains suboptimal. This study sought to determine the effect of an enhanced eGFR laboratory prompt containing specific management recommendations, compared with standard eGFR reporting in CKD. Design, setting, participants, & measurements A cluster randomized trial of a standard or enhanced eGFR laboratory prompt was performed in 93 primary care practices in Alberta, Canada. Although all adult patients with CKD (eGFR 2 ) were included, medication data were only available for elderly patients (aged ≥66 years). The primary outcome, the proportion of patients with diabetes or proteinuria receiving an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), was assessed in elderly CKD patients. Results There were 5444 elderly CKD patients with diabetes or proteinuria who were eligible for primary outcome assessment, irrespective of baseline ACEi/ARB use. ACEi/ARB use in the subsequent year was 77.1% and 76.9% in the standard and enhanced prompt groups, respectively. In the subgroup of elderly patients with an eGFR 2 , ACEi/ARB use was higher in the enhanced prompt group. Among 22,092 CKD patients, there was no difference in the likelihood of a composite clinical outcome (death, ESRD, doubling of serum creatinine, or hospitalization for myocardial infarction, heart failure, or stroke) over a median of 2.1 years. Conclusions In elderly patients with CKD and an indication for ACEi/ARB, an enhanced laboratory prompt did not increase use of these medications.

Medical Education 2012: 46: 299–305 Context Retroactive interference occurs when newly acquired information inhibits recall of previously learned information. This has been shown to influence recall of sounds, tastes and word associations, and is typically seen when learners receive training on one area of content and are then exposed to new content before being evaluated on the original content. Thus far, retroactive interference has received little attention in medical education and has not been studied during simulation training. Our objective was to evaluate whether retroactive interference occurs during simulation training. Methods We randomised 167 Year 1 medical students to one of two training protocols. After training on a cardiac murmur, participants were tested either on the same cardiac murmur followed by a novel murmur (the non-interference protocol), or on the novel murmur followed by the training murmur (the interference protocol). We evaluated performance on both murmurs at 1 hour and 6 weeks post-training. Results We found a significant interaction between training protocol and diagnostic performance on training versus novel murmurs at both testing time-points. Students in the non-interference protocol had increased odds of achieving success on the training murmur relative to the novel murmur at 1 hour (odds ratio [OR] 4.96; p

Background: This pilot study compared performance of University of Calgary students on internal clerkship examinations with corresponding National Board of Medical Examiners (NBME) subject examinations.Methods: Between April and October 2007, students completed internal and NBME subject examinations following six mandatory rotations. Local faculty within each discipline set the minimum performance level (MPL) for internal examinations. Two methods of standard setting were considered for NBME exams and a sensitivity analysis was performed. Corresponding internal and NBME examination scores were compared using McNemar’s discordant pair analysis.Results: A significant and unexpected difference in failure rate between internal and external examinations was found in all clerkships. 1.4% of students were below the MPL for internal examinations and 27.3% (modified Angoff) or 25.9% (mean Hofstee compromise) (p

Longitudinal integrated clerkship (LIC) students typically perform as well as, if not better than, rotation-based clerkship (RBC) students on objective evaluations, yet few studies have compared performance in the clinical setting. This study compared in-training evaluation report (ITER) ratings of LIC and RBC students, including their correlation with more objective evaluations.On the basis of prior academic performance, LIC students (n = 27) at Universities of Alberta, British Columbia, and Calgary were matched with four RBC students from their center. The authors compared reliability of ITER ratings, ITER ratings of clinical skills and professional attributes, and the correlation between ITER ratings and objective evaluations of clinical skills and professional attributes on the Medical Council of Canada Qualifying Examination (MCCQE) Part I.ITER ratings of LIC students were more reliable and significantly higher than those of RBC students for both clinical skills and professional attributes. However, LIC students had lower objective structured clinical examination scores and weaker correlations between subjective and objective evaluations of clinical skills. By comparison, LIC students scored higher on a particular component of the MCCQE and had stronger correlations between subjective and objective evaluations of professionalism.The discrepancy between ratings of LIC students' clinical skills on ITER and other evaluation formats may be due to differences between the content of training and objective evaluations, or systematic rater biases. Further studies are needed to confirm and explain these findings. Promisingly, our data suggest that the LIC model may allow for a more predictive evaluation of professional competencies.

Background: Nasopharyngeal papillomatosis is uncommon. Access and visualization make excision difficult, increasing the risk for recurrence. We present a novel technique for excision of nasopharyngeal papillomatosis. Methods: A case series of 3 patients with recurrent papilloma of the nasopharynx (NP) were treated with endoscopic transnasal coblation. We used an Arthrocare EVac 70 Coblator (setting: coblation-9, coagulation-5). Results: Using transnasal endoscopic coblation, we performed complete excision in 3 patients with recurrent papilloma of the NP (4 total procedures). There were no complications. One patient had a minor recurrence, which was successfully re-excised with the same technique. Conclusion: Nasopharyngeal papillomas can be difficult to excise. Multiple techniques have been described using a transoral approach, with no reported complications. However, surgical access to the entire NP is more challenging with a transoral approach. Also, bleeding and poor visualization secondary to bleeding can be encountered with these techniques. These problems were not encountered with transnasal coblation. The absence of eschar and decreased collateral thermal damage make coblation preferable to cauterization or laser excision. This proposed technique enables more complete visualization and removal of disease, which may reduce recurrence rates. © 2011 ARS-AAOA, LLC.

Despite limited data on patient outcomes, simulation training has already been adopted and embraced by a large number of medical schools. Yet widespread acceptance of simulation should not relieve us of the duty to demonstrate if, and under which circumstances, training learners on simulation benefits real patients. Here we review the data on performance of healthcare providers or trainees following simulation training, and discuss ways of enhancing transfer of learning from simulated to real patients. While there is tremendous potential for simulation in medical education and healthcare, further studies are needed to identify if and when simulation training improves the quality of care delivered to patients, and to compare the cost-effectiveness of simulated learning experiences to lower fidelity and less expensive interventions.

Many transplant candidates have concerns about living donation.To determine whether a structured educational session increased eligible kidney transplant candidates' pursuit of living donation.Eligible transplant candidates were randomized to standard of care (n = 50) or to the educational intervention (n = 50), which included both written materials and a 2-hour education session. The primary outcome was having a living donor contact the transplant program to express interest in donation for a patient, and a secondary outcome was the candidates' preference for treatment of end-stage renal disease; both outcomes were determined at 3 months after enrollment.Of the 100 patients randomized, 4 in the intervention group and 2 in the standard of care group had a living donor contact the program (P = .45). Within-group changes in treatment preference from baseline were seen in the education intervention group (P = .02), but not in the standard of care group (P = .37).This educational intervention did not increase the likelihood of a potential donor contacting the transplant program, compared with standard care. However, patients who received the educational intervention were more likely to change their treatment preference to living donation at study completion. Research investigating other methods of increasing living transplant rates is urgently required.

Previous studies have reached a variety of conclusions regarding the effect of gender on performance in objective structured clinical examinations (OSCEs). Most measured the effect on students' overall OSCE score. The authors of this study evaluated the effect of gender on the scores of specific physical examination OSCE stations, both "gender-sensitive" and "gender-neutral."In 2008, the authors collected scores for 138 second-year medical students at the University of Calgary who underwent a seven-station OSCE. Two stations--precordial and respiratory exams--were considered gender-sensitive. Multiple linear regression was used to explore the effect of students', standardized patients' (SPs'), and raters' genders on the students' scores.All 138 students (69 female) completed the OSCE and were included in the analyses. The mean scores (SD) for the two stations involving examination of the chest were higher for female than for male students (83.2% [15.5] versus 78.3% [15.8], respectively, d = 0.3, P = .009). There was a significant interaction between student and SP gender (P = .02). In the stratified analysis, female students were rated significantly higher than male students at stations with female SPs (85.4% [15.5] versus 76.6% [16.5], d = 0.6, P = .004) but not at stations with male SPs (80.2% [15.0] versus 80.0% [15.0], P = 1.0).These results suggest student and SP genders interact to affect OSCE scores at stations that require examination of the chest. Further investigations are warranted to ensure that the OSCE is an equal experience for all students.

PURPOSE Most diagnostic errors involve faulty diagnostic reasoning. Consequently, the authors assessed the effect of querying initial hypotheses on diagnostic performance. METHOD In 2007, the authors randomly assigned 67 first-year medical students from the University of Calgary to two groups and asked them to diagnose eight common problems. The authors presented the same primary data to both groups and asked students for their initial diagnosis. Then, after presenting secondary data that were either discordant or concordant with the primary data, they asked students for a final diagnosis. The authors noted changes in students' diagnoses and the accuracy of initial and final diagnoses for discordant and concordant cases. RESULTS For concordant cases, students retained 84.2% of their initial diagnoses and were equally likely to move toward a correct as incorrect final diagnosis (6.9% versus 8.9%, P = .3); no difference existed in the accuracy of initial and final diagnoses: 85.9% versus 84.0% (P = .4). By contrast, for discordant cases, students retained only 23.3% of initial diagnoses, change was almost invariably from incorrect to correct (76.3% versus 0.4%, P < .001), and final diagnoses were more accurate than initial diagnoses: 80.7% versus 4.8% (P < .001). Overall, no difference existed in the accuracy of final diagnoses for concordant and discordant cases (P = .18). CONCLUSIONS These data suggest that querying an initial diagnostic hypothesis does not harm a correct diagnosis but instead allows students to rectify an incorrect diagnosis. Whether querying initial diagnoses reduces diagnostic error in clinical practice remains unknown.

I ntroduction. If physicians apply clinical rather than biomedical knowledge when diagnosing, why do we use the basic sciences as the foundation for clinical teaching? In this study we evaluated the contribution of biomedical knowledge to diagnostic performance when solving electrolyte problems. Method. We asked 13 medical students and 19 nephrologists to solve electrolyte problems while thinking aloud, and determined biomedical knowledge application by protocol analysis. We used logistic regression to study the association between biomedical concepts, clinical experience, and performance. Results. Students and nephrologists applied a similar number of biomedical concepts per case (1.8 (±1.1) vs. 1.8 (±1.2), respectively, p = 0.8), but nephrologists were more successful (86.8% vs. 63.5%, p = 0.003). We found a significant interaction between expertise and applying biomedical concepts ( p < 0.05). For students the odds of success increased significantly with applying biomedical concepts (odds ratio 4.66 [2.07, 10.48], p < 0.001), whereas for nephrologists there was only a trend towards improved performance (odds ratio 1.72 [0.94, 3.11], p = 0.07). Conclusions. Our results suggest that improving biomedical knowledge of students should improve their performance on electrolyte problems. The performance of experienced physicians may also be improved, but this requires further study before teaching recommendations can be made.

Context The assessment of ethical problem solving in medicine has been controversial and challenging. The purposes of this study were: (i) to create a new instrument to measure doctors’ decisions on and reasoning approach towards resolving ethical problems; (ii) to evaluate the scores generated by the new instrument for their reliability and validity, and (iii) to compare doctors’ ethical reasoning abilities between countries and among medical students, residents and experts. Methods This study used 15 clinical vignettes and the think-aloud method to identify the processes and components involved in ethical problem solving. Subjects included volunteer ethics experts, postgraduate Year 2 residents and pre-clerkship medical students. The interview data were coded using the instruments of the decision score and Ethical Reasoning Inventory (ERI). The ERI assessed the quality of ethical reasoning for a particular case (Part I) and for an individual globally across all the vignettes (Part II). Results There were 17 Canadian and 32 Taiwanese subjects. Based on the Canadian standard, the decision scores between Taiwanese and Canadian subjects differed significantly, but made no discrimination among the three levels of expertise. Scores on the ERI Parts I and II, which reflect doctors’ reasoning quality, differed between countries and among different levels of expertise in Taiwan, providing evidence of construct validity. In addition, experts had a greater organised knowledge structure and considered more relevant variables in the process of arriving at ethical decisions than did residents or students. The reliability of ERI scores was 0.70–0.99 on Part I and 0.75–0.80 on Part II. Conclusions Expertise in solving ethical problems could not be differentiated by the decisions made, but could be differentiated according to the reasoning used to make those decisions. The difference between Taiwanese and Canadian experts suggests that cultural considerations come into play in the decisions that are made in the course of providing humane care to patients.

Context Despite the impartiality implied in its title, the objective structured clinical examination (OSCE) is vulnerable to systematic biases, particularly those affecting raters’ performance. In this study our aim was to examine OSCE ratings for evidence of differential rater function over time (DRIFT), and to explore potential causes of DRIFT. Methods We studied ratings for 14 internal medicine resident doctors over the course of a single formative OSCE, comprising 10 12-minute stations, each with a single rater. We evaluated the association between time-slot and rating for a station. We also explored a possible interaction between time-slot and station difficulty, which would support the hypothesis that rater fatigue causes DRIFT, and considered ‘warm-up’ as an alternative explanation for DRIFT by repeating our analysis after excluding the first two OSCE stations. Results Time-slot was positively associated with rating on a station (regression coefficient 0.88, 95% confidence interval [CI] 0.38–1.38; P = 0.001). There was an interaction between time-slot and station difficulty: for the more difficult stations the regression coefficient for time-slot was 1.24 (95% CI 0.55–1.93; P = 0.001) compared with 0.52 (95% CI − 0.08 to 1.13; P = 0.09) for the less difficult stations. Removing the first two stations from our analyses did not correct DRIFT. Conclusions Systematic biases, such as DRIFT, may compromise internal validity in an OSCE. Further work is needed to confirm this finding and to explore whether DRIFT also affects ratings on summative OSCEs. If confirmed, the factors contributing to DRIFT, and ways to reduce these, should then be explored.

As society's expectations of physicians change, so must the objectives of training. Professional organizations involved in training now emphasize multiplicity of roles. But how well do we evaluate these multiple roles?To investigate the principal components of evaluation in the Internal Medicine clerkship rotation at the University of Calgary.We performed factor analysis on all evaluation components in the Internal Medicine clerkship rotation, including the in-training evaluation report (ITER), objective structured clinical examination (OSCE), and multiple choice questions (MCQ) examination.We identified three principal components: information processing, professionalism, and declarative knowledge. Both the OSCE and MCQ loaded on a single factor, declarative knowledge. The nine items on the ITER loaded on two factors-information processing and professionalism.Despite using 11 evaluation items on three tools, we identified only three principal components of evaluation. Both our MCQ and OSCE appeared to measure declarative knowledge. The latter may be due to the fact that we use standardized patients without clinical findings-such that evaluations are primarily based upon the demonstration of examination routines. Reasons for the lack of discriminant validity of our ITER include overlapping attributes and constant errors, including a halo effect and an error of leniency.

CONTEXT The Royal College of Physicians and Surgeons of Canada (RCPSC) CanMEDS framework is being incorporated into specialty education worldwide. However, the literature on how to evaluate trainees in the CanMEDS competencies remains sparse. OBJECTIVES The goals of this study were to examine the assessment tools used and programme directors' perceptions of how well they evaluate performance of the CanMEDS roles in Canadian postgraduate training programmes. METHODS We conducted a web-based survey of programme directors of RCPSC-accredited training programmes. The survey consisted of two questions. Question 1 was designed to establish which assessment tools were used to assess each of the CanMEDS roles. Question 2 was intended to assess programme directors' perceived satisfaction with CanMEDS evaluation in their programmes. RESULTS A total of 149 of the eligible 280 programme directors participated in the survey. Programme directors used a variety of assessment tools to evaluate trainees in CanMEDS competencies. Programmes used more tools to evaluate the Medical Expert (mean = 4.03, standard deviation [SD] = 1.59) and Communicator (mean = 2.36, SD = 1.02) roles. Programme directors used the fewest tools for the Collaborator (mean = 1.75, SD = 1.10) and Manager (mean = 1.75, SD = 1.18) roles. More than 92% of the programmes used in-training evaluation reports to evaluate all the CanMEDS roles. Programme directors were satisfied with their evaluation of the Medical Expert role, but less so with assessment of the other CanMEDS competencies. CONCLUSIONS This study demonstrates that Canadian postgraduate training programmes use a variety of assessment tools to evaluate the CanMEDS competencies. Programme directors are neutral or concerned about how the CanMEDS roles other than that of Medical Expert are evaluated in their programmes. Further efforts are required to establish best practice in CanMEDS evaluation.

This article proposes a reconsideration of matthew Arnold's concept of disinterestedness in the context of the later writings of Kant and of recent discussions of messianism, in particular Giorgio Agamben's study of st. Paul. It argues that disin - terestedness in Arnold is a form of what Kant calls "moral fanaticism" based on the preservation of self-consciousness as the foundation of ethical and political obligation. By contrast, Arnold's most important early poems explore the possibility that conscious - ness might be self-interested and might seek a basis for moral and political action in the call to go beyond self-conscious experience. The following attempts to prepare the ground for such a reassessment of Arnold's early lyric poetry by analyzing the way the theory of the disinterestedness of culture involves a turn away from the direction the early poetry was beginning to take.

CONTEXT Previous studies have shown that an initial diagnostic hypothesis biases automatic information processing. It is unclear if an initial hypothesis has a similar effect on analytic information processing. Our first objective was to study the effect of an initial diagnostic hypothesis on analytic processing. Our second objective was to assess the effect of clinical experience on analytic processing by evaluating the effect of clinical frequency and urgency of an alternative diagnosis on diagnosis selection. METHODS During a 12-minute objective structured clinical examination station, 19 subspecialty medical residents diagnosed the cause of 3 clinical presentations: dyspnoea; headache, and chest pain. Subjects were randomly allocated cases for which the suggested initial hypothesis was either correct or incorrect. For cases with an incorrect initial hypothesis, the alternative diagnoses varied in the frequency with which they are encountered in clinical practice, and their clinical urgency, relative to the initial diagnostic hypothesis. RESULTS All correct initial hypotheses were retained, compared with 10.9% of incorrect hypotheses. All cases with a correct initial hypothesis were diagnosed correctly, compared with 65.2% of cases with an incorrect hypothesis (risk ratio 1.5 [95% confidence interval 1.2-1.9], P = 0.02). Clinical frequency and urgency were not associated with alternative diagnosis selection. DISCUSSION Our results suggest that an initial diagnostic hypothesis biases analytic processing. The data used to reject an initial hypothesis appear to drive selection of an alternative hypothesis. Further studies aimed at finding strategies for increasing the likelihood of generating a correct initial hypothesis or debiasing an initial hypothesis are needed.

Surveillance of the intra-access blood flow (Qa) has improved identification of thrombosis risk (Qa ≤ 500 ml/minute), and these patients are referred for angiogram and angioplasty. The purpose of this study was to correlate the Qa with patient and stenotic lesion characteristics both before and after angioplasty in a retrospective cohort of 210 patients who were preselected on the basis of reduced Qa (369 ± 121 ml/minute). Angiograms revealed a total of 643 stenoses, and all patients had at least one significant stenosis (>50% luminal narrowing). There was no significant association between the preangioplasty Qa and the number, location, or length of stenoses, but there was a significant negative correlation between the degree of stenosis and the preangioplasty Qa. Five hundred eighty stenoses in 190 patients were treated with angioplasty; the postangioplasty Qa was 633 ± 208 ml/minute. Of the residual stenoses, all had less than 50% narrowing. There was no correlation between the postangioplasty Qa and the length or degree of stenoses, but there was a significant negative correlation between the postangioplasty Qa and the number of stenoses. We conclude that the primary determinant of reduced preangioplasty Qa is the degree of stenosis, when stenoses are over 50%, whereas the primary determinant of reduced postangioplasty Qa is the number of stenosis. For patients with two or more residual stenoses and failure to achieve Qa > 500 p;ml/minute postangioplasty, the alternative procedure is a prompt surgical revision in order to maintain the goal of access patency.

Background Previous studies have suggested an association between reasoning strategies and diagnostic success, but the influence on this relationship of variables such as question format and task difficulty, has not been studied. Our objective was to study the association between question format, task difficulty, reasoning strategies and diagnostic success. Methods Study participants were 13 Internal Medicine residents at the University of Calgary. Each was given eight problem-solving questions in four clinical presentations and were randomized to groups that differed only in the question format, such that a question presented as short answer (SA) to the first group was presented as extended matching (EM) to the second group. There were equal numbers of SA/EM questions and straightforward/difficult tasks. Participants performed think-aloud during diagnostic reasoning. Data were analyzed using multiple logistic regression. Results Question format was associated with reasoning strategies; hypothetico-deductive reasoning being used more frequently on EM questions and scheme-inductive reasoning on SA questions. For SA question, non-analytic reasoning alone was used more frequently to answer straightforward cases than difficult cases, whereas for EM questions no such association was observed. EM format and straightforward task increased the odds of diagnostic success, whereas hypothetico-deductive reasoning was associated with reduced odds of success. Conclusions Question format and task difficulty both influence diagnostic reasoning strategies and studies that examine the effect of reasoning strategies on diagnostic success should control for these effects. Further studies are needed to investigate the effect of reasoning strategies on performance of different groups of learners.

The paper starts from Walter Benjamin's interpretation of the phrase "reason of state" that Paul Valery applies to Charles Baudelaire's poetry. After exploring how this phrase points to the interconnections between poetry and politics in Benjamin's writings on lyric, from the early essay on Holderlin to the later commentaries on Baudelaire, it goes on to explicate Baudelaire's reading of a book on the concept of reason of state by the Italian philosopher and historian Giuseppe Ferrari. The connections between Baudelaire's aesthetic theory of la modernite and Ferrari's politico-historical theory of reason of state are analyzed as a basis for reading a set of prose poems composed by Baudelaire during the period when he read Ferrari. Special attention is given to the poem from the Petits poemes en prose entitled "Les Veuves" ("The Widows").

Cu${}_{2}$SnS${}_{3}$ is a promising, earth-abundant photovoltaic material, but disorder in the positions of Cu and Sn cations in its crystal lattice complicate its electronic transport. The authors find that even after substantially increasing its cation ordering via annealing, minority-carrier transport is still dominated by disorder effects, as revealed by spectroscopy plus Monte Carlo simulations. These results identify important challenges to the implementation of Cu${}_{2}$SnS${}_{3}$ in solar cells, and carry implications for other semiconductors of this type, such as Cu${}_{2}$ZnSn(S,Se)${}_{4}$ (CZTS).

Clinical reasoning is dependent upon working memory (WM). More precisely, during the clinical reasoning process stored information within long-term memory is brought into WM to facilitate the internal deliberation that affords a clinician the ability to reason through a case. In the present study, we examined the relationship between clinical reasoning and WM while participants read clinical cases with functional magnetic resonance imaging (fMRI). More specifically, we examined the impact of clinical case difficulty (easy, hard) and clinician level of expertise (2nd year medical students, senior gastroenterologists) on neural activity within regions of cortex associated with WM (i.e., the prefrontal cortex) during the reasoning process. fMRI was used to scan ten second-year medical students and ten practicing gastroenterologists while they reasoned through sixteen clinical cases [eight straight forward (easy) and eight complex (hard)] during a single 1-h scanning session. Within-group analyses contrasted the easy and hard cases which were then subsequently utilized for a between-group analysis to examine effects of expertise (novice > expert, expert > novice). Reading clinical cases evoked multiple neural activations in occipital, prefrontal, parietal, and temporal cortical regions in both groups. Importantly, increased activation in the prefrontal cortex in novices for both easy and hard clinical cases suggests novices utilize WM more so than experts during clinical reasoning. We found that clinician level of expertise elicited differential activation of regions of the human prefrontal cortex associated with WM during clinical reasoning. This suggests there is an important relationship between clinical reasoning and human WM. As such, we suggest future models of clinical reasoning take into account that the use of WM is not consistent throughout all clinical reasoning tasks, and that memory structure may be utilized differently based on level of expertise.

To compare procedure-specific checklists and a global rating scale in assessing technical competence.Two trained raters used procedure-specific checklists and a global rating scale to independently evaluate 218 video-recorded performances of six bedside procedures of varying complexity for technical competence. The procedures were completed by 47 residents participating in a formative simulation-based objective structured clinical examination at the University of Calgary in 2011. Pass/fail (competent/not competent) decisions were based on an overall global assessment item on the global rating scale. Raters provided written comments on performances they deemed not competent. Checklist minimum passing levels were set using traditional standard-setting methods.For each procedure, the global rating scale demonstrated higher internal reliability and lower interrater reliability than the checklist. However, interrater reliability was almost perfect for decisions on competence using the overall global assessment (Kappa range: 0.84-1.00). Clinically significant procedural errors were most often cited as reasons for ratings of not competent. Using checklist scores to diagnose competence demonstrated acceptable discrimination: The area under the curve ranged from 0.84 (95% CI 0.72-0.97) to 0.93 (95% CI 0.82-1.00). Checklist minimum passing levels demonstrated high sensitivity but low specificity for diagnosing competence.Assessment using a global rating scale may be superior to assessment using a checklist for evaluation of technical competence. Traditional standard-setting methods may establish checklist cut scores with too-low specificity: High checklist scores did not rule out incompetence. The role of clinically significant errors in determining procedural competence should be further evaluated.

Most training programs use learners’ subjective ratings of their teachers as the primary measure of teaching effectiveness. In a recent study we found that preclinical medical students’ ratings of classroom teachers were associated with perceived charisma and physical attractiveness of the teacher, but not intellect. Here we explored whether the relationship between these variables and teaching effectiveness ratings holds in the clinical setting. We asked 27 Internal Medicine residents to rate teaching effectiveness of ten teachers with whom they had worked on a clinical rotation, in addition to rating each teacher’s clinical skills, physical attractiveness, and charisma. We used linear regression to study the association between these explanatory variables and teaching effectiveness ratings. We found no association between rating of physical attractiveness and teaching effectiveness. Clinical skill and charisma were independently associated with rating of teaching effectiveness (regression coefficients [95 % confidence interval] 0.73 [0.60, 0.85], p

Evolution from novice to expert is associated with the development of expert-type knowledge structure. The objectives of this study were to examine reliability and validity of concept sorting (ConSort©) as a measure of static knowledge structure and to determine the relationship between concepts in static knowledge structure and concepts used during diagnostic reasoning. ConSort© was used to identify static knowledge concepts and analysis of think-aloud protocols was used to identify dynamic knowledge concepts (used during diagnostic reasoning). Intra- and inter-rater reliability, and correlation across cases, were evaluated. Construct validity was evaluated by comparing proportions of nephrologists and students with expert-type knowledge structure. Sensitivity and specificity of static knowledge concepts as a predictor of dynamic knowledge concepts were estimated. Thirteen first-year medical students and 19 nephrologists participated. Intra- and inter-rater agreement for determination of static knowledge concepts were 1.0 and 0.90, respectively. Reliability across cases was 0.45. The proportions of nephrologists and students identified as having expert-type knowledge structure were 82.9% and 55.8%, respectively (p=0.001). Sensitivity and specificity of ConSort© in predicting concepts that were used during diagnostic reasoning were 96.8% and 27.8% for nephrologists and 87.2% and 55.1% for students. ConSort© is a reliable, valid and sensitive tool for studying static knowledge structure. The applicability of tools that evaluate static knowledge structure should be explored as an addition to existing tools that evaluate dynamic tasks such as diagnostic reasoning.

Background. The economic and health benefits of kidney transplantation are dependent on the length of allograft survival. High-resolution immunological screening can identify recipients at increased risk of early graft loss caused by acute rejection, but the use of these tests increases screening costs before transplantation. The objective of this study was to evaluate the cost-effectiveness of routine use of high-resolution flow-cytometry cross-matching and solid-phase screening for all recipients of primary deceased donor kidney transplants. Methods. A Markov model was constructed to evaluate costs and effects of two different clinical strategies on a simulated cohort of 1,000 transplant recipients: serological screening (SS) only and flow screening (FS) only. Outcomes measures were total cost of patient care over 25 years, life expectancy, quality-adjusted life expectancy, and transplant life expectancy. Results. In the base-case analysis, FS was associated with an average gain of 0.08 life years, 0.25 transplant life years, and 0.08 quality-adjusted life years per patient. SS was associated with a higher cost of CND$6,397 per patient, mostly because of increased use of dialysis in patients who suffered early graft loss under the SS strategy. The results were robust to uncertainty in the majority of variables, and a strategy using FS was cost-effective except under the unlikely scenario where the false-negative rate for SS was ≤2% or the early graft loss rate for flow-positive recipients was ≤7% (compared with 5% for flow-negative recipients). Conclusions. Routine use of FS in recipients of first-deceased donor kidney transplants is cost-effective.

The impact of education on chronic kidney disease patients' plans to initiate dialysis with self-care dialysis: A randomized trial.BackgroundCompared with in-center hemodialysis, self-care dialysis (including home and self-care hemodialysis and peritoneal dialysis) is less resource intensive and associated with similar clinical outcomes. However, utilization of self-care dialysis has been very low. We performed a randomized controlled trial in predialysis patients with chronic kidney disease (CKD) (GFR

The objective of this study was to design an examination blueprint for the Internal Medicine clerkship rotation that is congruent with both the learning objectives and delivered learning experiences and reflects the perceived importance of clinical presentations from both the students' and clinicians' perspectives. In this cross-sectional study 11 specialists in General Internal Medicine (GIM) and 11 clinical clerks at the University of Calgary were asked to score each of the 47 clinical presentations in the Internal Medicine clerkship rotation for 'impact' and 'frequency'. These attributes were used to provide an estimate of the relative importance of each clinical presentation. Statistical tests used were the Pearson's correlation coefficient and the Kappa statistic. Multi-attribute utility theory was applied to assess the best way of combining the variables of 'impact' and 'frequency'. The correlation between clerks and GIM specialists was 0.85 for the impact score and 0.86 for the frequency score (p < 0.001 for both). Corresponding Kappa values were 0.71 and 0.82, respectively (p < 0.001 for both). Combining impact and frequency as a multiplicative function produced a distribution that was positively skewed towards common, high impact presentations such as chest pain. We have created an examination blueprint that provides a realistic and objective measure of the relative importance of clinical presentations. Such a blueprint provides both face validity and content validity to the evaluation process.

Background: Live donor nephrectomy (LDN) is a major surgical procedure with an accepted low mortality and morbidity. Minimally invasive donor nephrectomy (MIDN) has been shown to decrease the wound morbidity associated with the lumbotomy of the classic open technique. Transplant programs face the challenge of initiating their MIDN programs without jeopardizing the safety of the donor and the graft quality. We present the experience at the University of Calgary after the initiation of a MIDN program, with a preoperative selective approach using the 3 major techniques for LDN. Methods: From December 2001 to May 2004, 50 consecutive, accepted, live kidney donors were evaluated and chosen to undergo nephrectomy by an open, laparoscopic, or hand-assisted technique. Patients were chosen for a particular technique based on the criteria of vascular anatomy, size of abdominal cavity, previous surgery, and technical implications for the recipient. Results: A total of 15 open, 11 laparoscopic, and 24 hand-assisted nephrectomies were performed. There were no statistically significant differences in sex, age, or body mass index between the groups. There were statistically significant differences in surgical times (P