Journal of medical education and training最新文献

Introduction: Type 2 diabetes is a significant problem among uninsured patients. Shared medical appointments (SMA) have been shown to improve outcomes in type 2 diabetes. We hypothesized that the SMA model could be adapted for a non-profit clinic in North Carolina that serves uninsured patients with diabetes that have incomes at/below 150% of the federal poverty line.

Research design and methods: We implemented and sustained a patient-driven, student-led SMA model that incorporated the monthly rotations of students, physician assistant, and undergraduate students as well as pharmacy residents and an endocrinologist who collectively provide diabetes care at the free clinic. SMA groups are 'open' cohorts and include 4-12 patients scheduled for the monthly clinic. Teams of transdisciplinary trainees work together to perform triage, medication reconciliation, brief history, and physical exam, after which patients participate in the SMA. The endocrinologist evaluates SMA patients individually during and after the visit.

Results: Between November 2015 and January 2017, we enrolled 29 patients in SMA. There was high variability in HbA1c at baseline. Among eight type 2 diabetes patients seen in endocrine clinic and with complete data one year before and after SMA implementation, the mean (SD) HbA1c before SMA was 9.7% ± 1.7% (83±7 mmol/ mol); mean HbA1c after SMA was 9.2% ± 1.8% (77 ± 8mmol/mol). The median HbA1c before SMA was 9.5% (80 mmol/mol); median HbA1c after SMA was 8.9% (74 mmol/mol). Overall, 6/8 patients showed decreased HbA1c after SMA although there was variability between individuals in response of glycemic control to SMA. SMA increased clinic efficiency and offered an opportunity to integrate transdisciplinary trainees. Trainees gain experience with novel models of care and the complexities of the patient experience of diabetes.

Conclusions: We hope this observation encourages others to implement such programs to enhance the evidence-base for SMA to address health disparities and increase the quality of free diabetes care.

Objective: The Accreditation Council for Graduate Medical Education (ACGME) has mandated that residency programs document progression of competency-based outcomes. The Ophthalmic Clinical Evaluation Exercise (OCEX) assesses clinical skills in ophthalmology residents during patient encounters. Although OCEX has been validated for assessing several of the ACGME-mandated competencies, it was unclear whether OCEX can measure the development of proficiency during residency. This study evaluated whether OCEX can discriminate skill levels across years in training.

Methods: In 2017, the authors performed a retrospective analysis on modified OCEX evaluations collected for 22 residents over 3 years at 2 residency programs. OCEX subcomponent scores were averaged to generate a mean score for each evaluation, followed by linear regression analysis for mean scores over time for individual residents. One-way ANOVA with repeated measures was used to compare scores aggregated over an academic year between resident classes. The authors also surveyed internal faculty evaluators and nationwide ophthalmology residency program directors on their use of OCEX.

Results: Mean OCEX scores for individual residents and resident class averages showed variable trajectories over the course of residency. There was no consistent effect of increasing level of training on scores. Surveys of evaluators and program directors indicated different interpretations of the grading scale anchors and irregular participation by faculty.

Conclusion: This dataset suggests that, despite clear behavioral anchors and faculty development on the use of the tool, evaluators still apply inconsistent grading standards that limit the OCEX from accurately monitoring longitudinal development of resident clinical performance in real-world practice.