Biomedical subjects
Rajesh S Mangrulkar
Publications and source records attributed to Rajesh S Mangrulkar.
Development of an evaluation of medical student competence in evidence-based medicine using a computer-based OSCE station.
BACKGROUND: Instruction in evidence-based medicine (EBM) has been widely incorporated into medical school curricula with little evidence of its effectiveness. Our goal was to create, implement, and validate a computer-based assessment tool that measured medical students' EBM skills. DESCRIPTION: As part of a required objective structured clinical examination, we developed a specific case scenario in which students (a) asked a structured clinical question using a standard framework, (b) generated effective MEDLINE search terms to answer a specific question, and (c) elected the most appropriate of 3 abstracts generated from a search justifying which best applies to the patient scenario. EVALUATION: Between the 3 blinded raters, there was very good interrater reliability with 84, 94, and 96% agreement on the scoring for each component, respectively (k = .64, .82, and .91, respectively). In addition, students found the station appropriately difficult for their level of training. CONCLUSIONS: This computer-based tool appears to measure several EBM skills independently and combines simple administration and scoring. Its generalizability to other cases and settings requires further study.
Effects of work hour reduction on residents' lives: a systematic review.
CONTEXT: The Accreditation Council for Graduate Medical Education implemented mandatory work hour limitations in July 2003, partly out of concern for residents' well-being in the setting of sleep deprivation. These limitations are likely to also have an impact on other aspects of the lives of residents. OBJECTIVE: To summarize the literature regarding the effect of interventions to reduce resident work hours on residents' education and quality of life. DATA SOURCES: We searched the English-language literature about resident work hours from 1966 through April 2005 using MEDLINE, EMBASE, and Current Contents, supplemented with hand-search of additional journals, reference list review, and review of abstracts from national meetings. STUDY SELECTION: Studies were included that assessed a system change designed to counteract the effects of resident work hours, fatigue, or sleep deprivation; included an outcome directly related to residents; and were conducted in the United States. DATA EXTRACTION: For each included study, 2 investigators independently abstracted data related to study quality, subjects, interventions, and findings using a standard data abstraction form. DATA SYNTHESIS: Fifty-four articles met inclusion criteria. The interventions used to decrease resident work hours varied but included night and day float teams, extra cross-coverage, and physician extenders. Outcomes included measures of resident education (operative experience, test scores, satisfaction) and quality of residents' lives (amount of sleep, well-being). Interventions to reduce resident work hours resulted in mixed effects on both operative experience and on perceived educational quality but generally improved residents' quality of life. Many studies had major limitations in their design or conduct. CONCLUSIONS: Past interventions suggest that residents' quality of life may improve with work hour limitations, but interpretation of the outcomes of these studies is hampered by suboptimal study design and the use of nonvalidated instruments. The long-term impact of reducing resident work hours on education remains unknown. Current and future interventions should be evaluated with more rigorous methods and should investigate links between residents' quality of life and quality of patient care.
Balancing continuity of care with residents' limited work hours: defining the implications.
The impact of the new resident work-hours rules on all aspects of patient care and education must be considered. While physician fatigue has taken center stage as the primary motivation behind this movement, the effect of these rules on the continuity of care for hospitalized patients needs to be critically analyzed from the perspectives of patients, physicians, and the health care system. The authors describe a conceptual framework that places continuity at the center and then considers the benefits and drawbacks of preserving continuity from the perspectives of the major stakeholders. They describe the categories of outcomes related to residents' fatigue and sleep deprivation that have been studied. Only a few studies have addressed patient outcomes, while most address resident outcomes. The authors discuss some of the possible solutions, including night float and the British system of shift work, and suggest that these solutions have different effects on each group of stakeholders, including both intended and unintended benefits and harms. Finally, the research agenda that arises from this framework is described. It includes taking into account multiple perspectives, identifying important outcomes, and considering unintended consequences. Using this framework, medical educators may better evaluate previous studies and consider remaining questions.
Systematic review: effects of resident work hours on patient safety.
BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) mandated new work hours rules for all residency programs in July 2003. PURPOSE: To critically evaluate the evidence that adhering to the ACGME standards will improve patient safety. DATA SOURCES: Searches of electronic databases (MEDLINE, EMBASE, PREMEDLINE, and Current Contents) and other methods to identify the English-language literature for studies on resident work hours for the years 1966 to 2004. STUDY SELECTION: Studies that assessed a system change designed to counteract the effects of work hours, fatigue, or sleep deprivation and that included an outcome related to patient safety were included. Seven studies met these criteria. DATA EXTRACTION: Two investigators abstracted data from all included studies by using a standard data abstraction form; each study was rated according to established criteria to assess study design quality. DATA SYNTHESIS: Interventions used were float systems, other cross-coverage systems, or unspecified schedule changes. Outcomes included mortality, adverse events, and medication errors. The results suggest that introducing such interventions has an unclear effect on selected patient safety indicators. Specifically, some indicators (such as mortality) may not change after interventions, while other indicators may improve or worsen. LIMITATIONS: This analysis is limited by the study designs of the included studies, the diversity of interventions in the studies, and the possibility of publication bias favoring studies that demonstrated statistically significant differences. CONCLUSION: Evidence on patient safety is insufficient to inform the process of reducing resident work hours.
Targeting and structuring information resource use: a path toward informed clinical decisions.
A core skill for all physicians to master is that of information manager. Despite a rapidly expanding set of electronic and print-based information resources, clinicians continue to answer their clinical queries predominantly through informal or formal consultation. Even as new tools are brought to market, the majority of them present information in a rigid fashion, presenting cumbersome user interfaces and inflexible data presentation. The need to rethink the structure of electronic information is paramount to improving the use of evidence at the bedside. As new tools are developed and educators teach clinicians to use them, the context for use of information resources must be considered, with special attention to physician work-flow, following the three paths outlined in this article. The process will be facilitated greatly by promoting evidence-based practice for the care of patients in the hospital and clinic setting.
What is the role of the clinical "pearl"?
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A computer-based OSCE station to measure competence in evidence-based medicine skills in medical students.
OBJECTIVE: To create a feasible, valid, and reliable tool to measure third-year medical students' skills in evidence-based medicine (EBM). DESCRIPTION: EBM skills-asking clinical questions, finding appropriate medical information resources, and appraising and applying them to patients-involve higher-order critical thinking abilities and are essential to being a competent physician. Students at our institution must pass a required OSCE exam at the end of their third year. As part of this exam, we developed a new 20-minute computer-based station to assess students' EBM skills. Using a specific case scenario, we asked the students to (1) ask a question using the population/intervention/comparison/outcome (PICO) framework; (2) generate appropriate search terms, given a specific question; and (3) select an appropriate abstract to answer a given question and state why two other abstracts were not appropriate. Prior to the assessment, we determined grading and passing criteria for each of the three components and for the station overall. Of the 140 students who completed the station, the percentages that passed the components were 71%, 81%, and 49% respectively, with only 29% passing all three parts. Preliminary analysis of psychometric properties of the station shows very good to excellent interrater reliability, with 65%, 67%, and 94% agreement on the scoring for the components, and kappas of.64,.82, and.94, respectively. DISCUSSION: Although there are many curricula for teaching EBM concepts, there are few tools to measure whether students are competent in applying their EBM skills. Our pilot station appears to be an innovative and promising tool to measure several EBM skills independently. By being computer-based, it is relatively simple to administer, grade, and evaluate. While preliminary data show good inter-rater reliability with our use of a single case, future work will include further testing of reliability and assessment of different types of cases. We will also use the results of this assessment to drive continuous improvement in our EBM curriculum. The students who completed this pilot station had not received an extensive formal EBM curriculum, whereas future groups will. We also will explore whether scores on our station correlate with those on other OSCE stations that also assess critical thinking skills, or if scores correlate with a student's clinical grades or overall class standing. We hope to test these hypotheses: (1) skills used in EBM are useful and valid measures of critical thinking abilities in learners and (2) tools such as ours will help to measure these essential competencies.