How to ... be a reflective practitioner.

ContextDevelopers of health care software have attributed improvements in patient
care to these applications. As with any health care intervention, such claims
require confirmation in clinical trials.ObjectivesTo review controlled trials assessing the effects of computerized clinical
decision support systems (CDSSs) and to identify study characteristics predicting
benefit.Data SourcesWe updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane
Library, Inspec, and ISI databases and consulting reference lists through
September 2004. Authors of 64 primary studies confirmed data or provided additional
information.Study SelectionWe included randomized and nonrandomized controlled trials that evaluated
the effect of a CDSS compared with care provided without a CDSS on practitioner
performance or patient outcomes.Data ExtractionTeams of 2 reviewers independently abstracted data on methods, setting,
CDSS and patient characteristics, and outcomes.Data SynthesisOne hundred studies met our inclusion criteria. The number and methodologic
quality of studies improved over time. The CDSS improved practitioner performance
in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of
10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease
management systems, and 19 (66%) of 29 drug-dosing or prescribing systems.
Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%)
reported improvements. Improved practitioner performance was associated with
CDSSs that automatically prompted users compared with requiring users to activate
the system (success in 73% of trials vs 47%; P = .02)
and studies in which the authors also developed the CDSS software compared
with studies in which the authors were not the developers (74% success vs
28%; respectively, P = .001).ConclusionsMany CDSSs improve practitioner performance. To date, the effects on
patient outcomes remain understudied and, when studied, inconsistent.

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

ContextCurrent assessment formats for physicians and trainees reliably test
core knowledge and basic skills. However, they may underemphasize some important
domains of professional medical practice, including interpersonal skills,
lifelong learning, professionalism, and integration of core knowledge into
clinical practice.ObjectivesTo propose a definition of professional competence, to review current
means for assessing it, and to suggest new approaches to assessment.Data SourcesWe searched the MEDLINE database from 1966 to 2001 and reference lists
of relevant articles for English-language studies of reliability or validity
of measures of competence of physicians, medical students, and residents.Study SelectionWe excluded articles of a purely descriptive nature, duplicate reports,
reviews, and opinions and position statements, which yielded 195 relevant
citations.Data ExtractionData were abstracted by 1 of us (R.M.E.). Quality criteria for inclusion
were broad, given the heterogeneity of interventions, complexity of outcome
measures, and paucity of randomized or longitudinal study designs.Data SynthesisWe generated an inclusive definition of competence: the habitual and
judicious use of communication, knowledge, technical skills, clinical reasoning,
emotions, values, and reflection in daily practice for the benefit of the
individual and the community being served. Aside from protecting the public
and limiting access to advanced training, assessments should foster habits
of learning and self-reflection and drive institutional change. Subjective,
multiple-choice, and standardized patient assessments, although reliable,
underemphasize important domains of professional competence: integration of
knowledge and skills, context of care, information management, teamwork, health
systems, and patient-physician relationships. Few assessments observe trainees
in real-life situations, incorporate the perspectives of peers and patients,
or use measures that predict clinical outcomes.ConclusionsIn addition to assessments of basic skills, new formats that assess
clinical reasoning, expert judgment, management of ambiguity, professionalism,
time management, learning strategies, and teamwork promise a multidimensional
assessment while maintaining adequate reliability and validity. Institutional
support, reflection, and mentoring must accompany the development of assessment
programs.

/pdf/defining-and-assessing-professional-competence-1sy606vpxu.pdf

Defining and Assessing Professional Competence

Background Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. Methods This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes thatshould generally be avoidedin persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to havespecific medical conditions. Results This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. Conclusions This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/757456/ioi20821.pdf

Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.

Objective: The objective of this study was to evaluate the impact of medication adherence on healthcare utilization and cost for 4 chronic conditions that are major drivers of drug spending: diabetes, hypertension, hypercholesterolemia, and congestive heart failure. Research Design: The authors conducted a retrospective cohort observation of patients who were continuously enrolled in medical and prescription benefit plans from June 1997 through May 1999. Patients were identified for disease-specific analysis based on claims for outpatient, emergency room, or inpatient services during the first 12 months of the study. Using an integrated analysis of administrative claims data, medical and drug utilization were measured during the 12-month period after patient identification. Medication adherence was defined by days’ supply of maintenance medications for each condition. Patients: The study consisted of a population-based sample of 137,277 patients under age 65. Measures: Disease-related and all-cause medical costs, drug costs, and hospitalization risk were measured. Using regression analysis, these measures were modeled at varying levels of medication adherence. Results: For diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs. For these conditions, higher medication costs were more than offset by medical cost reductions, producing a net reduction in overall healthcare costs. For diabetes, hypercholesterolemia, and hypertension, cost offsets were observed for all-cause medical costs at high levels of medication adherence. For all 4 conditions, hospitalization rates were significantly lower for patients with high medication adherence. Conclusions: For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy.

http://innovamedicaldesign.com/studies/Impact_of_Medication_Adherence.pdf

Impact of medication adherence on hospitalization risk and healthcare cost.

The authors describe a year-long faculty development initiative to develop leaders in medical education. The Teaching Scholars Program for Educators in the Health Sciences at McGill University enables faculty to improve their educational knowledge and skills while maintaining their clinical, teaching, and research responsibilities. The program, tailored to the participant's individual needs, consists of five main components: two university courses; independent study; participation in faculty-wide faculty development workshops and medical education rounds; a monthly seminar; and attendance at a national or international conference or course. Since its inception in 1997, 22 faculty members have completed the program; four are currently participating in it. This report discusses the experience of 15 scholars who completed the program by September 2000. Evaluations indicate that the scholars achieved most of their stated objectives. The university courses provided a foundation in educational principles and methodology; independent study allowed them to work on educational projects relevant to their disciplines; and the monthly seminars, faculty development workshops, and outside courses offered opportunities for skill acquisition and reflection. Participants also appreciated the opportunity to meet others interested in medical education and to become aware of available educational resources. A year after completing the program, many had joined new educational committees, taken on new leadership roles in medical education, and developed new courses for students and residents. Some of their projects had been presented at national meetings and were being prepared for publication. Two scholars had pursued further study at a master's level. Despite the ongoing challenge of protecting time for educational pursuits, this program has been beneficial in helping to develop educational leaders in the Faculty of Medicine.

A teaching scholars program to develop leaders in medical education.

Background Clinical teachers rarely receive formal instruction in the basic concepts and principles of education. It is usually assumed that expertise as a practitioner will translate into effectiveness as a teacher.

Purpose  To identify the important concepts and pedagogic principles, which, if known and understood by clinical practitioners, might enhance their teaching prowess and success.

Method  We developed a long list of potentially important concepts identified in the education literature. We then conducted a 3-round Delphi expert opinion-soliciting process to identify which of the concepts were of most importance to clinical teachers.

Results  Thirteen of the 14 panel members successfully completed the process and achieved 94% reliability in rating the potential importance of the concepts on the e-mailed ratings list.

Conclusion  We have identified a limited list of core pedagogic concepts, knowledge of which may enhance the success of clinical teachers.

The ABCs of pedagogy for clinical teachers.

OBJECTIVES Participants in faculty development workshops often comment that 'those who need faculty development the most attend the least'. The goals of this study were to explore the reasons why some clinical teachers do not participate in centralised faculty development activities and to learn how we can make faculty development programmes more relevant to teachers' needs. METHODS In 2006, we conducted focus groups with 16 clinical teachers, who had not participated in faculty development activities, to ascertain their perceptions of faculty development, reasons for non-participation and perceived barriers to involvement. Content analysis and team consensus guided the data interpretation. RESULTS Focus group participants were aware of faculty development offerings and valued the goals of these activities. Important reasons for non-participation emerged: clinical reality, which included volume of work and lack of (protected) time; logistical issues, such as timing and the central location of organised activities; a perceived lack of financial reward and recognition for teaching, and a perceived lack of direction from, and connection to, the university. CONCLUSIONS Clinical reality and logistical issues appeared to be greater deterrents to participation than faculty development goals, content or strategies. Moreover, when asked to discuss faculty development, teachers referred to their development as faculty members in the broadest sense, which included personal and career development. They also expressed the desire for clear guidance from the university, financial rewards and recognition for teaching, and a sense of 'belonging'. Faculty development programmes should try to address these organisational issues as well as teachers' personal and professional needs.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2923.2008.03246.x

Faculty development: a 'field of dreams'?

Background: Although educational innovations in medical education are increasing in number, many educators do not submit their ideas for publication. Aims: The goal of this initiative was to assist faculty members write about their educational innovations. Method: Twenty-four faculty members participated in this intervention, which consisted of a half-day workshop, three peer writing groups, and independent study. We assessed the impact of this intervention through post-workshop evaluations, a oneyear follow-up questionnaire, tracking of manuscript submissions, and an analysis of curriculum vitae. Results: The workshop evaluations and one-year follow-up demonstrated that participants valued the workshop small groups, self-instructional workbook, and peer support and feedback provided by the peer writing groups. One year later, nine participants submitted a total of 14 manuscripts, 11 of which were accepted for publication. In addition, 10 participants presented a total of 38

https://informahealthcare.com/doi/pdf/10.1080/01421590802337120

Writing for publication in medical education: The benefits of a faculty development workshop and peer writing group

The Teaching Scholars Program for Educators in the Health Sciences at McGill University, in Montreal, Quebec, was designed to promote the professional development of health science educators by increasing their expertise in developing and implementing educational programs and taking on leade

Peter J. McLeod

Papers

A teaching scholars program to develop leaders in medical education.

The ABCs of pedagogy for clinical teachers.

Faculty development: a 'field of dreams'?

Writing for publication in medical education: The benefits of a faculty development workshop and peer writing group

From novice to informed educator: the teaching scholars program for educators in the health sciences.