Recent Publications by CFE Educators

PURPOSE

This study examined the teaching points made by preceptors in response to two videotaped teaching encounters to determine if (1) different preceptors use similar teaching points in response to the same case, (2) preceptors' teaching points vary by case, and (3) preceptors' teaching points vary by teaching model (One-Minute Preceptor and traditional preceptor models).

METHOD

Preceptors (n = 116) at seven universities participated in a within-groups experimental design study in 2000. The preceptors viewed videotaped encounters depicting two cases and two precepting models. They were asked to list two teaching points after viewing the initial case presentations and after the teaching encounters were completed. Frequency of teaching points listed by preceptors was examined for each case and teaching model. Teaching points were coded using qualitative methods and then analyzed using repeated-measures analysis of variance.

RESULTS

Of the 843 total teaching points identified by preceptors, 63 were discrete teaching points that were aggregated into 15 categories. Most preceptors (82%) listed three to five separate teaching points, which varied significantly by case and model. Those observing the traditional precepting model were more likely to teach generic skills such as history-taking skills, presentation skills, and risk factors, and those observing the One-Minute Preceptor were more likely to teach about the illness focusing on a broader differential diagnosis, further diagnostic tests, and the natural presentation of disease.

CONCLUSIONS

Preceptors use three to five common teaching points that vary by case and teaching model. The One-Minute Preceptor model shifted teaching points away from generic clinical skills toward disease-specific teaching.

PURPOSE

To compare the One-Minute Preceptor (OMP) and traditional models of ambulatory teaching in terms of the preceptors' (1) ability to correctly diagnose patients' medical problems, (2) ability to rate students' skills and confidence in doing so, and (3) satisfaction with both models.

METHOD

A within-groups experimental design study was conducted with 116 preceptors at seven universities in 2000. Participants viewed scripted, videotaped precepting encounters of both models using two cases and were asked to rate students' abilities, their confidence in rating the students' abilities, and the effectiveness and efficiency of the teaching encounters.

RESULTS

Preceptors who viewed the videotapes of the OMP model were equally or better able to correctly diagnose the patients' medical conditions than those viewing the traditional model. Preceptors viewing the OMP rated students' abilities higher on history taking/physical examination, presentations, clinical reasoning, and fund of knowledge than did those viewing the traditional model. Preceptors viewing the OMP rated themselves as more confident in rating students' abilities in presentation, clinical reasoning, and fund of knowledge. Preceptors rated the OMP as more effective and more efficient than the traditional model.

CONCLUSIONS

Preceptors viewing scripted, videotaped teaching encounters using the OMP model were equal to or better able to correctly diagnose patients' medical problems, had greater self-confidence in rating students, and rated the encounter as more effective and efficient than when viewing the traditional model.

Using the Genetic Analysis Workshop 13 simulated data set, we compared the technique of importance sampling to several other methods designed to adjust p-values for multiple testing: the Bonferroni correction, the method proposed by Feingold et al., and naïve Monte Carlo simulation. We performed affected sib-pair linkage analysis for each of the 100 replicates for each of five binary traits and adjusted the derived p-values using each of the correction methods. The type I error rates for each correction method and the ability of each of the methods to detect loci known to influence trait values were compared. All of the methods considered were conservative with respect to type I error, especially the Bonferroni method. The ability of these methods to detect trait loci was also low. However, this may be partially due to a limitation inherent in our binary trait definitions.

Markers of maturation and activation were measured on peripheral CD4+ T cells in chronically HIV-1-infected patients in a randomized, controlled pilot study of structured treatment interruption (STI). Eight subjects underwent 2 cycles of 1 month off and 1 month on highly active antiretroviral therapy (HAART), followed by a final 3-month interruption. During STI, CD4+ T-cell percentage remained relatively stable in 4 of 8 subjects. The remaining 4 STI subjects had significant rapid decline in CD4+ T-cell percentage during STI, followed by return to pre-STI baseline while on HAART. Changes in overall CD4+ T-cell percentage corresponded with fluctuations in the CD45RA+CCR7+ naive and CD45RA-CCR7+ central memory subsets. Subjects with variable CD4+ T-cell percentages tended to have higher pre-HAART plasma HIV-1 RNA set-points and experienced higher levels of plasma HIV-1 RNA rebound during STI. These results suggest that interruptions should be avoided whenever possible in patients on HAART with high plasma HIV-1 RNA set-points.

CONTEXT

Morbidity and mortality conferences in residency programs are intended to discuss adverse events and errors with a goal to improve patient care. Little is known about whether residency training programs are accomplishing this goal.

OBJECTIVE

To determine the frequency at which morbidity and mortality conference case presentations include adverse events and errors and whether the errors are discussed and attributed to a particular cause.

DESIGN, SETTING, AND PARTICIPANTS

Prospective survey conducted by trained physician observers from July 2000 through April 2001 on 332 morbidity and mortality conference case presentations and discussions in internal medicine (n = 100) and surgery (n = 232) at 4 US academic hospitals.

MAIN OUTCOME MEASURES

Frequencies of presentation of adverse events and errors, discussion of errors, and attribution of errors.

RESULTS

In internal medicine morbidity and mortality conferences, case presentations and discussions were 3 times longer than in surgery conferences (34.1 minutes vs 11.7 minutes; P =.001), more time was spent listening to invited speakers (43.1% vs 0%; P.001), and less time was spent in audience discussion (15.2% vs 36.6%; P.001). Fewer internal medicine case presentations included adverse events (37 [37%] vs 166 surgery case presentations [72%]; P.001) or errors causing an adverse event (18 [18%] vs 98 [42%], respectively; P =.001). When an error caused an adverse event, the error was discussed as an error less often in internal medicine (10 errors [48%] vs 85 errors in surgery [77%]; P =.02). Errors were attributed to a particular cause less often in medicine than in surgery conferences (8 [38%] of 21 medicine errors vs 88 [79%] of 112 surgery errors; P.001). In discussions of cases with errors, conference leaders in both internal medicine and surgery infrequently used explicit language to signal that an error was being discussed and infrequently acknowledged having made an error.

CONCLUSIONS

Our findings call into question whether adverse events and errors are routinely discussed in internal medicine training programs. Although adverse events and errors were discussed frequently in surgery cases, teachers in both surgery and internal medicine missed opportunities to model recognition of error and to use explicit language in error discussion by acknowledging their personal experiences with error.

Agonists at serotonin 1D (5-HT1D) receptors relieve migraine headache but are not clinically used as general analgesics. One possible explanation for this difference is that 5-HT1D receptors are preferentially expressed by cranial afferents of the trigeminal system. We compared the distribution of 5-HT1D receptor-immunoreactive (5-HT1D-IR) peripheral afferents within the trigeminal ganglion (TRG) and lumbar dorsal root ganglion (DRG) of the rat. We also examined the neurochemical identity of 5-HT1D-IR neurons with markers of primary afferent nociceptors, peripherin, isolectin B4, and substance P, and markers of myelinated afferents, N52 and SSEA3. We observed a striking similarity in the size, distribution, and neurochemical identity of 5-HT1D-IR neurons in TRG and lumbar DRG afferents. Furthermore, the vast majority of 5-HT1D-IR neurons are unmyelinated peptidergic afferents that distribute peripherally, including the dura, cornea, and the sciatic nerve. In the central projections of these afferents within the trigeminal nucleus caudalis and the spinal cord dorsal horn, 5-HT1D-IR fibers are concentrated in laminas I and outer II; a few axons penetrate to lamina V. At the ultrastructural level, 5-HT1D receptors in the spinal cord dorsal horn are localized exclusively within dense core vesicles of synaptic terminals. We observed scattered 5-HT1D-IR neurons in the nodose ganglia, and there was sparse terminal immunoreactivity in the solitary nucleus. The visceral efferents of the superior cervical ganglia did not contain 5-HT1D immunoreactivity. Our finding, that 5-HT1D receptors are distributed in nociceptors throughout the body, raises the possibility that triptans can regulate not only headache-associated pain but also nociceptive responses in extracranial tissues.

Acute basilar artery occlusion has a mortality rate approaching 90%. The authors describe a case of acute basilar artery occlusion managed successfully with endovascular embolectomy. A 31-year-old man sought treatment for confusion, dysarthria, and right-sided weakness. He soon became unresponsive and was found to have a vertebral artery dissection and an associated basilar artery embolism. The dissection was managed with endovascular stenting, and the basilar artery embolus was removed with a clot retriever at 7 hours. The patient recovered without neurologic deficit.