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Ongoing transformations in health professions education underscore the need for valid and reliable assessment. The current standard for assessment validation requires evidence from five sources: content, response process, internal structure, relations with other variables, and consequences. However, researchers remain uncertain regarding the types of data that contribute to each evidence source. We sought to enumerate the validity evidence sources and supporting data elements for assessments using technology-enhanced simulation. We conducted a systematic literature search including MEDLINE, ERIC, and Scopus through May 2011. We included original research that evaluated the validity of simulation-based assessment scores using two or more evidence sources. Working in duplicate, we abstracted information on the prevalence of each evidence source and the underlying data elements. Among 217 eligible studies only six (3 %) referenced the five-source framework, and 51 (24 %) made no reference to any validity framework. The most common evidence sources and data elements were: relations with other variables (94 % of studies; reported most often as variation in simulator scores across training levels), internal structure (76 %; supported by reliability data or item analysis), and content (63 %; reported as expert panels or modification of existing instruments). Evidence of response process and consequences were each present in <10 % of studies. We conclude that relations with training level appear to be overrepresented in this field, while evidence of consequences and response process are infrequently reported. Validation science will be improved as educators use established frameworks to collect and interpret evidence from the full spectrum of possible sources and elements.

In simulation-based health professions education, the concept of simulator fidelity is usually understood as the degree to which a simulator looks, feels, and acts like a human patient. Although this can be a useful guide in designing simulators, this definition emphasizes technological advances and physical resemblance over principles of educational effectiveness. In fact, several empirical studies have shown that the degree of fidelity appears to be independent of educational effectiveness. The authors confronted these issues while conducting a recent systematic review of simulation-based health professions education, and in this Perspective they use their experience in conducting that review to examine key concepts and assumptions surrounding the topic of fidelity in simulation.Several concepts typically associated with fidelity are more useful in explaining educational effectiveness, such as transfer of learning, learner engagement, and suspension of disbelief. Given that these concepts more directly influence properties of the learning experience, the authors make the following recommendations: (1) abandon the term fidelity in simulation-based health professions education and replace it with terms reflecting the underlying primary concepts of physical resemblance and functional task alignment; (2) make a shift away from the current emphasis on physical resemblance to a focus on functional correspondence between the simulator and the applied context; and (3) focus on methods to enhance educational effectiveness using principles of transfer of learning, learner engagement, and suspension of disbelief. These recommendations clarify underlying concepts for researchers in simulation-based health professions education and will help advance this burgeoning field.

This article provides an overview of cognitive load theory (CLT) and explores applications of CLT to health profession and nursing education research, particularly for multimedia and simulation-based applications. The article first reviews the 3 components of cognitive load: intrinsic, extraneous, and germane. It then discusses strategies for manipulating cognitive load variables to enhance instruction. Examples of how CLT variables can be modulated during instruction are provided. Lastly, the article discusses current applications of CLT to health profession and nursing education research and presents future research directions, focusing on the areas of multimedia and simulation-based learning., (Copyright© by Ingram School of Nursing, McGill University.)

Context: The optimal learner to simulator ratio for procedural skills training is not known. Research in motor learning suggests observational training in pairs, termed 'dyad training', may be as effective as directed self-regulated learning (DSRL)., Objectives: This study was conducted to compare the relative effectiveness and efficiency of dyad versus DSRL training of simulation-based lumbar puncture (LP)., Methods: We conducted a two-group randomised equivalence trial. First-year internal medicine residents (n = 50) were randomly assigned to learn LP either in dyads or as individual learners on a simulator, using a directed self-regulated approach (i.e. the learning sequence was defined for them, but they defined the pace of learning). Participants were videotaped performing a simulated LP on a pre-test, an immediate post-test, and a 6-week delayed retention test. In duplicate, blinded raters independently evaluated all trainee performances using a previously validated 5-point global rating scale (GRS) and 35-item checklist., Results: Our analyses showed no significant differences (p = 0.69) on pre-test, post-test or retention test GRS scores between the dyad (mean ± standard deviation [SD] scores by test: 2.39 ± 0.57, 3.48 ± 0.62, 3.12 ± 0.85, respectively) and DSRL (mean ± SD scores by test: 2.67 ± 0.50, 3.34 ± 0.77, 3.21 ± 0.79, respectively) groups. Both groups improved significantly from pre-test to post-test (p < 0.001) and retained that performance following the 6-week delay. Dyad participants experienced significantly greater pre-test to post-test gains than DSRL participants (p = 0.02). There was no significant difference in total practice time between the groups (20.94 minutes for individuals and 24.20 minutes for dyads; p = 0.175)., Conclusions: Our results indicate that learning in pairs is as effective as independent DSRL. Dyad training permits the more efficient use of simulators as two learners use the same resources as an individual., (© 2013 John Wiley & Sons Ltd.)

Use of dual-processing has been widely touted as a strategy to reduce diagnostic error in clinical medicine. However, this strategy has not been tested among medical trainees with complex diagnostic problems. We sought to determine whether dual-processing instruction could reduce diagnostic error across a spectrum of experience with trainees undertaking cardiac physical exam. Three experiments were conducted using a similar design to teach cardiac physical exam using a cardiopulmonary simulator. One experiment was conducted in each of three groups: experienced, intermediate and novice trainees. In all three experiments, participants were randomized to receive undirected or dual-processing verbal instruction during teaching, practice and testing phases. When tested, dual-processing instruction did not change the probability assigned to the correct diagnosis in any of the three experiments. Among intermediates, there was an apparent interaction between the diagnosis tested and the effect of dual-processing instruction. Among relative novices, dual processing instruction may have dampened the harmful effect of a bias away from the correct diagnosis. Further work is needed to define the role of dual-processing instruction to reduce cognitive error. This study suggests that it cannot be blindly applied to complex diagnostic problems such as cardiac physical exam.

Purpose: Competency-based education requires individualization of instruction. Mastery learning, an instructional approach requiring learners to achieve a defined proficiency before proceeding to the next instructional objective, offers one approach to individualization. The authors sought to summarize the quantitative outcomes of mastery learning simulation-based medical education (SBME) in comparison with no intervention and nonmastery instruction, and to determine what features of mastery SBME make it effective., Method: The authors searched MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, Scopus, key journals, and previous review bibliographies through May 2011. They included original research in any language evaluating mastery SBME, in comparison with any intervention or no intervention, for practicing and student physicians, nurses, and other health professionals. Working in duplicate, they abstracted information on trainees, instructional design (interactivity, feedback, repetitions, and learning time), study design, and outcomes., Results: They identified 82 studies evaluating mastery SBME. In comparison with no intervention, mastery SBME was associated with large effects on skills (41 studies; effect size [ES] 1.29 [95% confidence interval, 1.08-1.50]) and moderate effects on patient outcomes (11 studies; ES 0.73 [95% CI, 0.36-1.10]). In comparison with nonmastery SBME instruction, mastery learning was associated with large benefit in skills (3 studies; effect size 1.17 [95% CI, 0.29-2.05]) but required more time. Pretraining and additional practice improved outcomes but, again, took longer. Studies exploring enhanced feedback and self-regulated learning in the mastery model showed mixed results., Conclusions: Limited evidence suggests that mastery learning SBME is superior to nonmastery instruction but takes more time.

Purpose: To summarize the tool characteristics, sources of validity evidence, methodological quality, and reporting quality for studies of technology-enhanced simulation-based assessments for health professions learners., Method: The authors conducted a systematic review, searching MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous reviews through May 2011. They selected original research in any language evaluating simulation-based assessment of practicing and student physicians, nurses, and other health professionals. Reviewers working in duplicate evaluated validity evidence using Messick's five-source framework; methodological quality using the Medical Education Research Study Quality Instrument and the revised Quality Assessment of Diagnostic Accuracy Studies; and reporting quality using the Standards for Reporting Diagnostic Accuracy and Guidelines for Reporting Reliability and Agreement Studies., Results: Of 417 studies, 350 (84%) involved physicians at some stage in training. Most focused on procedural skills, including minimally invasive surgery (N=142), open surgery (81), and endoscopy (67). Common elements of validity evidence included relations with trainee experience (N=306), content (142), relations with other measures (128), and interrater reliability (124). Of the 217 studies reporting more than one element of evidence, most were judged as having high or unclear risk of bias due to selective sampling (N=192) or test procedures (132). Only 64% proposed a plan for interpreting the evidence to be presented (validity argument)., Conclusions: Validity evidence for simulation-based assessments is sparse and is concentrated within specific specialties, tools, and sources of validity evidence. The methodological and reporting quality of assessment studies leaves much room for improvement.

Objectives: The current review examines the effectiveness of simulation-based medical education (SBME) for training health professionals in cardiac physical examination and examines the relative effectiveness of key instructional design features., Methods: Data sources included a comprehensive, systematic search of MEDLINE, EMBASE, CINAHL, PsychINFO, ERIC, Web of Science, and Scopus through May 2011. Included studies investigated SBME to teach health profession learners cardiac physical examination skills using outcomes of knowledge or skill. We carried out duplicate assessment of study quality and data abstraction and pooled effect sizes using random effects., Results: We identified 18 articles for inclusion. Thirteen compared SBME to no-intervention (either single group pre-post comparisons or SBME added to other instruction common to all learners, such as traditional bedside teaching), three compared SBME to other educational interventions, and two compared two SBME interventions. Meta-analysis of the 13 no-intervention comparison studies demonstrated that simulation-based instruction in cardiac auscultation was effective, with pooled effect sizes of 1.10 (95 % CI 0.49-1.72; p < 0.001; I(2) = 92.4 %) for knowledge outcomes and 0.87 (95 % CI 0.52-1.22; p < 0.001; I(2) = 91.5 %) for skills. In sub-group analysis, hands-on practice with the simulator appeared to be an important teaching technique. Narrative review of the comparative effectiveness studies suggests that SBME may be of similar effectiveness to other active educational interventions, but more studies are required., Limitations: The quantity of published evidence and the relative lack of comparative effectiveness studies limit this review., Conclusions: SBME is an effective educational strategy for teaching cardiac auscultation. Future studies should focus on comparing key instructional design features and establishing SBME's relative effectiveness compared to other educational interventions.

Background: Although technology-enhanced simulation is increasingly used in health professions education, features of effective simulation-based instructional design remain uncertain., Aims: Evaluate the effectiveness of instructional design features through a systematic review of studies comparing different simulation-based interventions., Methods: We systematically searched MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, Scopus, key journals, and previous review bibliographies through May 2011. We included original research studies that compared one simulation intervention with another and involved health professions learners. Working in duplicate, we evaluated study quality and abstracted information on learners, outcomes, and instructional design features. We pooled results using random effects meta-analysis., Results: From a pool of 10,903 articles we identified 289 eligible studies enrolling 18,971 trainees, including 208 randomized trials. Inconsistency was usually large (I2 > 50%). For skills outcomes, pooled effect sizes (positive numbers favoring the instructional design feature) were 0.68 for range of difficulty (20 studies; p < 0.001), 0.68 for repetitive practice (7 studies; p = 0.06), 0.66 for distributed practice (6 studies; p = 0.03), 0.65 for interactivity (89 studies; p < 0.001), 0.62 for multiple learning strategies (70 studies; p < 0.001), 0.52 for individualized learning (59 studies; p < 0.001), 0.45 for mastery learning (3 studies; p = 0.57), 0.44 for feedback (80 studies; p < 0.001), 0.34 for longer time (23 studies; p = 0.005), 0.20 for clinical variation (16 studies; p = 0.24), and -0.22 for group training (8 studies; p = 0.09)., Conclusions: These results confirm quantitatively the effectiveness of several instructional design features in simulation-based education.

To determine the comparative effectiveness of technology-enhanced simulation, we summarized the results of studies comparing technology-enhanced simulation training with nonsimulation instruction for health professions learners. We systematically searched databases including MEDLINE, Embase, and Scopus through May 2011 for relevant articles. Working in duplicate, we abstracted information on instructional design, outcomes, and study quality. From 10,903 candidate articles, we identified 92 eligible studies. In random-effects meta-analysis, pooled effect sizes (positive numbers favoring simulation) were as follows: satisfaction outcomes, 0.59 (95% confidence interval, 0.36-0.81; n = 20 studies); knowledge, 0.30 (0.16-0.43; n = 42); time measure of skills, 0.33 (0.00-0.66; n = 14); process measure of skills, 0.38 (0.24-0.52; n = 51); product measure of skills, 0.66 (0.30-1.02; n = 11); time measure of behavior, 0.56 (-0.07 to 1.18; n = 7); process measure of behavior, 0.77 (-0.13 to 1.66; n = 11); and patient effects, 0.36 (-0.06 to 0.78; n = 9). For 5 studies reporting comparative costs, simulation was more expensive and more effective. In summary, in comparison with other instruction, technology-enhanced simulation is associated with small to moderate positive effects.

The use of checklists is recommended for the assessment of competency in central venous catheterization (CVC) insertion. To explore the use of a global rating scale in the assessment of CVC skills, this study seeks to compare its use with two checklists, within the context of a formative examination using simulation. Video-recorded performances of CVC insertion by 34 first-year medical residents were reviewed by two independent, trained evaluators. Each evaluator used three assessment tools: a ten-item checklist, a 21-item checklist, and a nine-item global rating scale. Exploratory principal component analysis of the global rating scale revealed two factors, accounting for 84.1% of the variance: technical ability and safety. The two checklist scores correlated positively with the weighted factor score on technical ability (0.49 [95% CI 0.17-0.71] for the 10-item checklist; 0.43 [95% CI 0.10-0.67] for the 21-item checklist) and negatively with the weighted factor score on safety (-0.17 [95% CI -0.48-0.18] for the 10-item checklist; -0.13 [95% CI -0.45-0.22] for the 21-item checklist). A checklist score of <80% was strong indication of incompetence. However, a high checklist score did not preclude incompetence. Ratings using the global rating scale identified an additional 11 candidates (32%) who were deemed incompetent despite scoring >80% on both checklists. All these candidates committed serious errors. In conclusion, the practice of universal adoption of checklists as the preferred method of assessment of procedural skills should be questioned. The inclusion of global rating scales should be considered.

Background: Fixed-dose combination treatments using an angiotensin-converting enzyme (ACE) inhibitor, such as perindopril, plus a calcium channel blocker (CCB), such as amlodipine, have been endorsed by guidelines because they improve blood pressure control and cardiovascular outcomes in hypertensive patients, while being well tolerated and well adhered to by patients., Objective: This study aimed to assess the blood pressure-lowering effects of fixed-combination perindopril/amlodipine in patients previously treated with an ACE inhibitor and/or a CCB., Methods: This was a prospective, real-life, open-label, longitudinal, phase IV study conducted in 223 outpatient medical centres across Slovakia. 2132 previously treated patients whose hypertension was insufficiently controlled at baseline or who tolerated treatment poorly were included. Patients were treated for 3 months with fixed-combination perindopril/amlodipine 5 mg/5 mg, 5 mg/10 mg, 10 mg/5 mg and 10 mg/10 mg. The main outcome measure was a reduction in mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) and achievement of blood pressure targets (SBP/DBP <140/90 mmHg or <130/80 mmHg for patients with type 2 diabetes mellitus or high cardiovascular risk)., Results: After 3 months of treatment, mean ± SD SBP/DBP had decreased from 158.5 ± 17.5/93.6 ± 9.8 mmHg to 132.9 ± 10.6/80.7 ± 6.2 mmHg (p < 0.0001). In patients with grade 3 hypertension, mean ± SD changes from baseline in SBP/DBP were -45.4 ± 16.4/-20.0 ± 11.5 mmHg after 3 months (p < 0.0001). Blood pressure targets were reached by 74% of the overall patient population, 84% of patients with grade 1 hypertension, and 52% of difficult-to-treat patients with grade 3 hypertension. This treatment was associated with a 58% reduction in the number of patients with amlodipine-related ankle oedema compared with baseline., Conclusion: Fixed-combination perindopril/amlodipine was well tolerated and resulted in statistically significant and clinically meaningful decreases in blood pressure.

Objectives: Simulation training offers opportunities for unsupervised, self-regulated learning, yet little evidence is available to indicate the efficacy of this approach in the learning of procedural skills. We evaluated the effectiveness of directed self-regulated learning (DSRL) and instructor-regulated learning (IRL), respectively, for teaching lumbar puncture (LP) using simulation., Methods: We randomly assigned internal medicine residents in postgraduate year 1 to either DSRL ('directed' to progress from easy to difficult LP simulators during self-regulated learning) or IRL (in groups of four led by an instructor). All participants practised for up to 50 minutes and completed a pre-test, post-test and delayed (by 3 months) retention test on the simulator. Pairs of blinded trained experts independently rated all videotaped performances using a validated global rating scale and a modified version of a validated checklist. Participants provided measures of LP experience and self-reported confidence. We analysed the pre-post (n = 42) and pre-post-retention performance scores (n = 23) using two separate repeated-measures analyses of variance (anovas) and computed Pearson correlation coefficients between participants' confidence and performance scores., Results: Inter-rater agreement was strong for both performance measures (intra-class correlation coefficient > 0.81). The groups achieved similar pre-test and post-test scores (p > 0.05) and scores in both groups improved significantly from the pre- to the post-test (p < 0.05). On retention, a significant interaction (F(2,42) = 3.92, p = 0.03) suggests the DSRL group maintained its post-test performance, whereas that in the IRL group dropped significantly (p < 0.05). Correlations between self-reported confidence and post-test performance were positive and significant for the DSRL group, and negative and non-significant for the IRL group., Conclusions: Both IRL and DSRL led to improved LP performance immediately after practice. Whereas the IRL group's skills declined after 3 months, the DSRL group's performance was maintained, suggesting a potential long-term benefit of this training. Participants in the DSRL group also developed a more accurate relationship between confidence and competence following practice. Further research is needed to clarify the mechanisms of self-regulated learning and its role in simulation contexts., (© Blackwell Publishing Ltd 2012.)

Purpose: Most efforts to develop reliable evaluations of clinical competence have been oriented toward deconstructing the requisite competencies into separate scales. However, many are questioning the value of this approach on theoretical and empirical bases. This study uses "standardized narratives" to explore a different approach to assessing resident performance., Method: In 2009, based on interviews with 19 experienced clinical faculty from two institutions, 16 narrative profiles were created to represent the range of resident competence that clinical faculty might encounter during supervision. Fourteen clinicians from three institutions independently grouped the profiles into as many categories as necessary to reflect various levels of performance, described their categories, then ranked the individual profiles within each category. Then, in groups of three or four, participants negotiated a final ranking and grouping of the 16 profiles., Results: Despite interesting idiosyncracies in the factors some participants identified as guiding their rankings, there was strong consistency across the 14 clinicians regarding the rankings (single-rater intraclass correlation [ICC] = 0.86) and groupings (single-rater ICC = 0.81) of the profiles. Similarly, across institutions, the four groups were highly consistent in their final negotiated rankings (single-group ICC = 0.91) and groupings (single-group ICC = 0.87) of the profiles., Conclusions: Faculty showed more consistency in their decisions of what constitutes excellent, competent, and problematic performance in residents than implied by current assessment techniques that require deconstruction of resident competencies. This use of standardized narratives points to interesting opportunities for more authentically codifying faculty opinions of residents.

Background: The quality of medical student and resident clinical evaluation reports submitted by rotation supervisors is a concern. The effectiveness of faculty development (FD) interventions in changing report quality is uncertain., Aims: This study assessed whether faculty could be trained to complete higher quality reports., Method: A 3-h interactive program designed to improve evaluation report quality, previously developed and tested locally, was offered at three different Canadian medical schools. To assess for a change in report quality, three reports completed by each supervisor prior to the workshop and all reports completed for 6 months following the workshop were evaluated by three blinded, independent raters using the Completed Clinical Evaluation Report Rating (CCERR): a validated scale that assesses report quality., Results: A total of 22 supervisors from multiple specialties participated. The mean CCERR score for reports completed after the workshop was significantly higher (21.74 ± 4.91 versus 18.90 ± 5.00, p = 0.02)., Conclusions: This study demonstrates that this FD workshop had a positive impact upon the quality of the participants' evaluation reports suggesting that faculty have the potential to be trained with regards to trainee assessment. This adds to the literature which suggests that FD is an important component in improving assessment quality.

Background: Traditional Objective Structured Clinical Examinations (OSCEs) are psychometrically sound but have the limitation of fragmenting complex clinical cases into brief stations. We describe a pilot study of a modified OSCE that attempts to balance a typical OSCE format with a semblance of a continuous, complex, patient case., Methods: Two OSCE scenarios were developed. Each scenario involved a single standardized patient and was subdivided into three sequential 10 minute sections that assessed separate content areas and competencies. Twenty Canadian PGY-4 internal medicine trainees were assessed by trained examiner pairs during each OSCE scenario. Paired examiners rated participant performance independent of each other, on each section of each scenario using a validated global rating scale. Inter-rater reliabilities and Pearson correlations between ratings of the 3 sections of each scenario were calculated. A generalizability study was conducted. Participant and examiner satisfaction was surveyed., Results: There was no main effect of section or scenario. Inter-rater reliability was acceptable. The g-coefficient was 0.68; four scenarios would achieve 0.80. Moderate correlations between sections of a scenario suggest a possible halo effect. The majority of examiners and participants felt that the modified OSCE provided a sense of patient continuity., Conclusions: The modified OSCE provides another approach to the assessment of clinical performance. It attempts to balance the advantages of a traditional OSCE with a sense of patient continuity.

Background: The purpose of this study was to evaluate the reliability and acceptance of the mini-Clinical Evaluation Exercise (mini-CEX) as an assessment of practicing primary care physicians., Method: Six raters were recruited to conduct the assessments. After a training session, their ability to discriminate between levels of performance was evaluated using videotaped clinical scenarios. Fifteen physicians were assessed in an office setting by the raters who scored multiple clinical encounters using a validated mini-CEX form for each encounter. Participants were given a postassessment survey regarding the process., Results: Raters distinguished between performance levels on the videotaped scenarios (P < .001). A total of 188 physician-patient interactions were assessed. The generalizability coefficient for 10 encounters was 0.92. In the postassessment survey, the raters (94%) and physicians assessed (75%) both felt that the mini-CEX is an acceptable assessment., Conclusions: The mini-CEX seems to be a reliable and acceptable instrument for the assessment of practicing physicians.

Introduction: Objective outcome measures for use with simulator-based assessments of cardiac physical examination competence are lacking. The current study describes the development and validation of an approach to scoring performance using a cardiac findings checklist., Methods: A cardiac findings checklist was developed and implemented for use with a simulator-based assessment of cardiac physical examination competence at a Canadian national specialty examination in internal medicine. Candidate performance as measured using the checklist was compared with global ratings of clinical performance on the cardiac patient simulator and with overall examination performance., Results: Interrater reliability for scoring the checklist ranged from 0.95 for scoring correct findings to 0.72 for scoring incorrect findings. A summary checklist score had a Pearson correlation of 0.60 with overall candidate performance on the simulator-based station., Conclusion: Use of a cardiac findings checklist provides one objective measure of cardiac physical examination competence that may be used with simulator-based assessments.

Purpose: Properly conducted clinical trials provide essential evidence about the benefits and harms of a therapeutic intervention. To ensure accurate interpretation of study findings urologists should understand measures of effect and their precision. In this segment of the Users' Guide to the Urological Literature series we provide guidance on how measures of effect and precision should be interpreted and used in the evidence-based practice of urology., Materials and Methods: Using an example from the urology literature we define commonly used measures of effect and describe how these statistics can be readily generated from the results of a clinical trial. We also highlight the importance of confidence interval interpretations when critically appraising study findings., Results: The effect of an intervention can be described in absolute or relative terms. Risk of an event, risk difference and number needed to treat are easy to interpret, and allow the patient and urologist to assess the impact of an intervention in absolute terms. Relative measures of effect (relative risk, relative risk reduction) also characterize the treatment effect and can be applied to patients with varying baseline risk. The degree of precision within which the study estimated the actual effect size may be ascertained from the associated confidence interval. Confidence intervals are also useful when interpreting the benefit and harm of an experimental intervention and, therefore, are preferred compared to p values., Conclusions: Urologists do not need to rely on author interpretations of the effectiveness or harmfulness of a given intervention alone, but may interpret the result of the study themselves. An understanding of measures of effect size and precision is important to the interpretation of the urological literature and facilitates evidence-based clinical practice.

Objective: High-stakes assessments of doctors' physical examination skills often employ standardised patients (SPs) who lack physical abnormalities. Simulation technology provides additional opportunities to assess these skills by mimicking physical abnormalities. The current study examined the relationship between internists' cardiac physical examination competence as assessed with simulation technology compared with that assessed with real patients (RPs)., Methods: The cardiac physical examination skills and bedside diagnostic accuracy of 28 internists were assessed during an objective structured clinical examination (OSCE). The OSCE included 3 modalities of cardiac patients: RPs with cardiac abnormalities; SPs combined with computer-based, audio-video simulations of auscultatory abnormalities, and a cardiac patient simulator (CPS) manikin. Four cardiac diagnoses and their associated cardiac findings were matched across modalities. At each station, 2 examiners independently rated a participant's physical examination technique and global clinical competence. Two investigators separately scored diagnostic accuracy., Results: Inter-rater reliability between examiners for global ratings (GRs) ranged from 0.75-0.78 for the different modalities. Although there was no significant difference between participants' mean GRs for each modality, the correlations between participants' performances on each modality were low to modest: RP versus SP, r = 0.19; RP versus CPS, r = 0.22; SP versus CPS, r = 0.57 (P < 0.01)., Conclusions: Methodological limitations included variability between modalities in the components contributing to examiners' GRs, a paucity of objective outcome measures and restricted case sampling. No modality provided a clear 'gold standard' for the assessment of cardiac physical examination competence. These limitations need to be addressed before determining the optimal patient modality for high-stakes assessment purposes.

Background: The mini-clinical evaluation exercise (mini-CEX) is a 30 minute observed clinical encounter which allows assessment of a resident's clinical competence with feedback on their performance., Aims: To assess residents' perceptions of the mini-CEX using qualitative methods., Methods: After introducing the mini-CEX into the University of British Columbia's Internal Medicine Residency Program, a one hour semi-structured focus group with voluntary first and second year residents was undertaken. The focus groups were conducted by an independent moderator, audio-taped, and transcribed verbatim. Using a phenomenological approach, the comments made by the focus group participants were read independently by the three authors and organized into major themes., Results: The major themes included Education, Assessment and Exam Preparation. Residents described a conflict between the mini-CEX's role as a method of assessment and its utility as an educational tool. During initial mini-CEX encounters, they perceived the assessment format as anxiety-provoking. Over time, they felt that the mini-CEX provided insight into their clinical competence. Participants believed that the mini-CEX experience would benefit them in preparation and successful completion of their national specialty exam., Conclusions: Residents' perceptions of the mini-CEX reflected a tension between the tool's dual roles of assessment and education.

Background: Many standardized patient (SP) encounters employ SPs without physical findings and, thus, assess physical examination technique. The relationship between technique, accurate bedside diagnosis, and global competence in physical examination remains unclear., Method: Twenty-eight internists undertook a cardiac physical examination objective structured clinical examination, using three modalities: real cardiac patients (RP), "normal" SPs combined with related cardiac audio-video simulations, and a cardiology patient simulator (CPS). Two examiners assessed physical examination technique and global bedside competence. Accuracy of cardiac diagnosis was scored separately., Results: The correlation coefficients between participants' physical examination technique and diagnostic accuracy were 0.39 for RP (P < .05), 0.29 for SP, and 0.30 for CPS. Patient modality impacted the relative weighting of technique and diagnostic accuracy in the determination of global competence., Conclusions: Assessments of physical examination competence should evaluate both technique and diagnostic accuracy. Patient modality affects the relative contributions of each outcome towards a global rating.

Aim: To examine the relationship between a physician's ability to examine a standardized patient (SP) and their ability to correctly identify related clinical findings created with simulation technology., Method: The authors conducted an observational study of 347 candidates during a Canadian national specialty examination at the end of post-graduate internal medicine training. Stations were created that combined physical examination of an SP with evaluation of a related audio-video simulation of a patient abnormality, in the domains of cardiology and neurology. Examiners evaluated a candidate's competence at performing a physical examination of an SP and their accuracy in diagnosing a related audio-video simulation., Results: For the cardiology stations, the correlation between the physical examination scores and recognition of simulation abnormalities was 0.31 (p < 0.01). For the neurology stations, the correlation was 0.27 (p < 0.01). Addition of the simulations identified 18% of 197 passing candidates on the cardiology stations and 17% of 240 passing candidates on the neurology stations who were competent in their physical examination technique but did not achieve the passing score for diagnostic skills., Conclusions: Assessments incorporating SPs without physical findings may need to include other methodologies to assess bedside diagnostic acumen.

Purpose: To evaluate the reliability and validity of the Mini-Clinical Evaluation Exercise (mini-CEX) for postgraduate year 4 (PGY-4) internal medicine trainees compared to a high-stakes assessment of clinical competence, the Royal College of Physicians and Surgeons of Canada Comprehensive Examination in Internal Medicine (RCPSC IM examination)., Methods: Twenty-two PGY-4 residents at the University of British Columbia and the University of Calgary were evaluated, during the 6 months preceding their 2004 RCPSC IM examination, with a mean of 5.5 mini-CEX encounters (range 3-6). Experienced Royal College examiners from each site travelled to the alternate university to assess the encounters., Results: The mini-CEX encounters assessed a broad range of internal medicine patient problems. The inter-encounter reliability for the residents' mean mini-CEX overall clinical competence score was 0.74. The attenuated correlation between residents' mini-CEX overall clinical competence score and their 2004 RCPSC IM oral examination score was 0.59 (P = 0.01)., Conclusion: By examining multiple sources of validity evidence, this study suggests that the mini-CEX provides a reliable and valid assessment of clinical competence for PGY-4 trainees in internal medicine.

Incorporating evidence-based medicine (EBM) into clinical practice is an important competency that residency training must address. Residency program directors, and the clinical educators who work with them, should develop curricula to enhance residents' capacity for independent evidence-based practice. In this article, the authors argue that residency programs must move beyond journal club formats to promote the practice of EBM by trainees. The authors highlight the limitations of journal club, and suggest additional curricular approaches for an integrated EBM curriculum. Helping residents become effective evidence users will require a sustained effort on the part of residents, faculty, and their educational institutions.

High-stakes assessment of clinical performance through the use of standardized patients (SPs) is limited by the SP's lack of real physical abnormalities. The authors report on the development and implementation of physical examination stations that combine simulation technology in the form of digitized cardiac auscultation videos with an SP assessment for the 2003 Royal College of Physicians and Surgeons of Canada's Comprehensive Objective Examination in Internal Medicine. The authors assessed candidates on both the traditional stations and the stations that combined the traditional SP examination with the digitized cardiac auscultation video. For the combined stations, candidates first completed a physical examination of the SP, watched and listened to a computer simulation, and then described their auscultatory findings. The candidates' mean scores for both types of stations were similar, as were the mean discrimination indices for both types of stations, suggesting that the combined stations were of a testing standard similar to the traditional stations. Combining an SP with simulation technology may be one approach to the assessment of clinical competence in high-stakes testing situations.

Arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) is a progressive disease of predominantly right ventricle, characterized by ventricular arrhythmias possible leading to sudden cardiac death. Genetic predisposition was confirmed more than 15 years ago. Autosomal dominant are forms ARVD1-9, Naxos disease (with subtype Carvajal syndrome) is recessive. In ARVC/D forms associated with desmosomal disorders are ventricular arrhythmias caused by the presence of myocardial damage and in forms associated with ryanodine receptor mutation is electrical instability and subsequent myocardial damage caused by calcium cell overload. Main clinical signs are ventricular arrhythmias originated from areas with slow conduction. Progression of ARVC/D is manifested by RV dilatation and LV echocardiographic abnormalities both considered as main risk factors of fatal ventricular arrhythmias and sudden cardiac death. Therapeutic possibilities include antiarrhythmic drugs, catheter ablation and implantation of cardioverter-defibrillator, in severe right or both ventricle involvement even heart failure treatment (Tab. 1, Ref. 56).

Objectives: The aim of this study was to evaluate changes in QRST integral maps in patients with ARVC., Background: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a progressive disorder of predominantly right ventricle characterized with arrhythmic events possibly leading to sudden cardiac death. QRST integral maps reflect local disparities of ventricular repolarization and resulting vulnerability to arrhythmias., Methods: A group of 8 patients with ARVC and a control group of 8 patients with a concealed accessory pathway were studied. Body surface mapping was performed using a 63-lead Savard's system., Results: Mean QRST integral map of patients with ARVC showed abnormal characteristics. The area of negativity was larger than normal and extended to lower border of thorax. Departure map of the mean QRST integral map of patients with ARVC showed areas with departure index < 2 and > 2 in lower part of chest and upper part of back. When statistically analyzed, areas with p < 0.05 covered nearly lower half of chest and upper half of back., Conclusions: We consider body surface QRST integral mapping to be an adequate method for evaluation of dispersion of ventricular repolarization in ARVC patients (Tab. 1, Fig. 5, Ref. 17).

The right ventricular apex has been used as the traditional pacing site since the development of transvenous pacing in 1959. Some studies suggest that pacing the right ventricular apex may cause remodeling and is harmful. In the past decade, there have been a multitude of studies of the hemodynamic, electrophysiological, electrocardiographic, and clinical effects of ventricular pacing at other sites. Pacing of the left ventricle singly or with biventricular pacing has emerged as an effective and safe therapy for moderate to severe congestive heart failure in patients with prolonged QRS complexes. Studies of alternate right ventricular sites, like the right ventricular outflow tract, have given mixed results. Not all patients can be treated with left ventricular pacing, which is a time-consuming and difficult procedure. Right ventricular pacing is easier and less expensive than left ventricular pacing and further study of additional right ventricular sites seems warranted.

Aims: To determine whether the loss of repetitive slow pathway conduction identifies a successful radiofrequency ablation of atrioventricular nodal reentry tachycardia (AVNRT)., Methods and Results: Thirty nine consecutive patients undergoing ablation of AVNRT using the slow pathway approach were included. At baseline and after each radiofrequency application with an episode of junctional rhythm, repetitive slow pathway conduction was assessed as follows: Effective refractory period of the fast pathway was determined. The coupling interval of the first atrial extrastimulus (A2) was set at 30 ms below the effective refractory period of the fast pathway to ensure its conduction via the slow pathway. The second atrial extrastimulus (A3) was introduced at progressively longer coupling intervals starting from 200 ms until: (1) it propagated to the His bundle or (2) an anterogradely blocked AV nodal echo of A2 appeared before a conducted A3 depolarized the atrium in the His bundle electrogram. The response was termed repetitive slow pathway conduction if A3 was conducted with an AH > 200 ms. Application was considered successful if no AVNRT could be induced. Repetitive slow pathway conduction was present after 1 of 39 successful and after 34 of 40 ineffective applications (P < 0.0001). Repetitive slow pathway conduction identified a successful application with 97% sensitivity, 86% specificity, 86% positive predictive value, and 97% negative predictive value., Conclusion: The presence of repetitive slow pathway conduction identifies an unsuccessful application with a clinically meaningful negative predictive value.

The incidence of atrial fibrillation (AF) is increasing in many countries along with aging demographics. Atrial fibrillation is clearly associated with an increased rate of stroke. Numerous large clinical trials have shown that dose-adjusted warfarin can reduce the stroke rate in these patients, particularly in the elderly, and clear guidelines for the use of anticoagulants in such patients have been published. However, many studies show that treatment rates remain disappointingly low (< or = 50%). Numerous barriers to the use of dose-adjusted warfarin exist, including practical, patient-, physician-, and healthcare system-related barriers. These include the complex pharmacokinetics of warfarin, the need for continuous prothrombin time monitoring and dose adjustments, bleeding events, noncompliance, drug interactions, and increased costs of monitoring and therapy. Possible solutions to this problem are discussed and include improved patient and physician education, the use of anticoagulation clinics, new approaches to AF, and potential treatment improvements through use of newer anticoagulants.

Purpose: A written test of clinical decision-making, the Key Features Examination, was developed for use in clerkship., Methods: Following the guidelines provided by the Medical Council of Canada, a Key Features Examination was developed and implemented in an internal medicine clinical clerkship, during the 1998/99 clerkship year. The reliability and concurrent validity of the exam were assessed., Results: A 2 hour examination, containing 15 key feature problems, was administered to 101 students during 6 consecutive internal medicine clerkship rotations. The reliability of the exam, calculated from Cronbach's alpha, was 0.49. The exam had modest correlation with other measures of knowledge and clinical performance., Conclusion: The Key Feature Examination is a feasible and reliable evaluation tool that may be implemented as a component of student assessment during a clinical clerkship.

This article reviews the complex character of neuroendocrine response to paroxysmal tachycardia. While the endocrine influences in arrhythmogenesis are well perceived by the cardiologists, less attention has been paid to influence of tachycardia on neuroendocrine activation. However, this may significantly alter the clinical course of tachycardias and its responses to pharmacotherapeutic interventions. Main characteristics of hormones with direct relationship to cardiovascular system (ANP, AVP, catecholamines, angiotensin and others) are listed with description of regulation of their secretion and main biological effects, especially with regard to regulation of circulation. Changes in hemodynamics during tachycardia with accompanying changes in ANP, AVP renin-angiotensin-aldosterone system, sympatho-neural and sympatho-adrenal activation are reviewed. Further research and understanding require more complex approach and concentration on interrelationship of different regulatory hormones in tachycardia. (Fig. 2, Ref. 96.)

Background: The implantable cardioverter/defibrillator (ICD) has been shown to be superior to antiarrhythmic drug therapy for the secondary prevention of sudden cardiac death. Its role in the primary prevention of sudden death after myocardial infarction is unknown. Methods and Results The Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) is a randomized, open-label, parallel-group comparison of ICD therapy versus no ICD therapy in selected survivors of acute myocardial infarction. It will test the hypothesis that reduction of sudden arrhythmogenic death by means of the ICD will result in reduction of overall mortality rates in patients at high risk after acute myocardial infarction. Accordingly, this international multicenter study aims to enroll patients shortly after their infarction (day 6 to day 40) who have reduced left ventricular function (left ventricular ejection fraction

Gender bias, described among practicing physicians, has rarely been examined in medical students. The current study examined the influence of gender bias on medical students' clinical decision making. We experimentally manipulated patient gender in 27 written clinical vignettes embedded in the United States Medical Licensing Examination (USMLE) Step 2 examination (a multiple-choice test of clinical decision making). Female and male patient versions of selected test cases were created within three categories: (1) diseases with previously established evidence of gender bias in the diagnosis or management of the disease, (2) diseases with a higher prevalence in a specific gender, and (3) diseases with similar prevalence in both genders and without evidence of gender bias in the literature. Among the 3059 students who wrote the USMLE Step 2 examination in August 1998, there were small but significant differences in performance on the 12 gender bias cases. Students performed worse for the female patient version of the cases compared with the male patient version of the cases (mean of 55.8% correct for female cases compared with 57.7% correct for male cases) (p < 0. 01). Our data suggest that students were variably influenced by gender bias in their investigation and management of patients in a written test of clinical decision making.

With an increasing number of available treatment options, clinicians must frequently evaluate whether comparable therapies are equivalent in terms of efficacy and safety. Two methodologically distinct study designs are used to establish therapeutic equivalence: standard superiority trials and true equivalence trials. In either study design, clinician-readers assess equivalence by examining both the statistical significance and the clinical importance of the study results (as defined by the minimally important difference, the smallest difference in patient outcome that would lead to an important difference in patient health status). Once therapeutic equivalence has been established, clinicians may select one therapy as the preferred treatment option because it offers other clinical benefits, such as a lower cost or a more convenient drug administration schedule.

To examine the effect of clinical history on the electrocardiogram (ECG) interpretation skills of physicians with different levels of expertise, we randomly allocated to an ECG test package 30 final-year medical students, 15 second-year internal medicine residents, and 15 university cardiologists at university-affiliated teaching hospitals. All participants interpreted the same set of 10 ECGs. Each ECG was accompanied by a brief clinical history suggestive of the correct ECG diagnosis, or the most plausible alternative diagnosis, or no history. Provision of a correct history improved accuracy by 4% to 12% compared with no history, depending on level of training. Conversely, a misleading history compared with no history reduced accuracy by 5% for cardiologists, 25% for residents, and 19% for students. Clinical history also affected the participants' frequencies of listing ECG features consistent with the correct diagnosis and features consistent with the alternative diagnosis (all p values < .05). For physicians at all levels of expertise, clinical history has an influence on ECG diagnostic accuracy, both improving accuracy when the history suggests the correct diagnosis, and reducing accuracy when the history suggests an alternative diagnosis.

Arrhythmogenic dysplasia of the right ventricle as a nosological entity was described relatively recently. However, at present, it is gradually being diagnosed more frequently. The authors describe the typical clinical picture of this disease in one of several patients with this disease, who were hospitalised at SUSCH. The authors describe the diagnostical value of individual findings. They indicate the importance of knowledge of individual diagnostical criteria in order to be able to recognize this disease and distinguish it from idiopathic ventricular tachycardia, the prognosis of which is generally better and also the therapeutical approach less aggressive. (Fig. 6, Ref. 29).

Background: Transoesophageal cardiostimulation is a semiinvasive method of stimulation of atrii enabling the performance of the programmed atrial stimulation without the inevitability of an invasive vascular approach. This method was used in 124 patients with the following indication spectrum. Diagnostic indications: total 82%, paroxysmal supraventricular tachycardia (SVT), and WPW sy-22%, tachycardia with wide QRS-complex-8%. SSS syndrome and bradycardia-20%, sycopes and collapses with unclear etiology-13%, palpitations-11%, control of antiarrhythmic therapy-4%, and other states-6%. Therapeutic indications: total-18%, versions of paroxysmal SVT and flutter of atrii., Results: The patients with SVT were assumed to develop the arrhythmogenic mechanism--AV nodal re-entry tachycardia in 80%, orthodrome AV-re-entry tachycardia in 30%, and flutter of atrii in 20%. All patients with WPW-syndrome were stratified by the use of this method. The origin of this state from ventricular arrhythmia was verified in 40% of patients with tachycardia with a wide QRS complex. In coincidence with other indications, the diagnostic benefit of transoesophageal cardiostimulation was evaluated as follows: syncopes-68%, palpitations-64%, syndrome SSS and bradycardia-48%. The therapeutic indication of SVT version and flutter of atrii, was totally successful in 40%, partly successful in 45% and unsuccessful in 15% of patients., Conclusion: Transoesophageal cardiostimulation has contributed to the assessment of the diagnosis in 69% of patients and has acutely managed arrhythmia in 85% of cases. According to our experience, this method is effective in the initial management of patients with arrhythmia. Its low technical and economic demands make its wider utilisation appropriate in clinical practice of internal medicine. (Tab. 4, Fig. 9, Ref. 22).