Managing the complexity of doing it all : an exploratory study on students' experiences when trained stepwise in conducting consultations

Background: At most medical schools the components required to conduct a consultation, medical knowledge, communication, clinical reasoning and physical examination skills, are trained separately. Afterwards, all the knowledge and skills students acquired must be integrated into complete consultations, an art that lies at the heart of the medical profession. Inevitably, students experience conducting consultations as complex and challenging. Literature emphasizes the importance of three didactic course principles: moving from partial tasks to whole task learning, diminishing supervisors' support and gradually increasing students' responsibility. This study explores students' experiences of an integrated consultation course using these three didactic principles to support them in this difficult task. Methods: Six focus groups were conducted with 20 pre-clerkship and 19 clerkship students in total. Discussions were audiotaped, transcribed and analysed by Nvivo using the constant comparative strategy within a thematic analysis. Results: Conducting complete consultations motivated students in their learning process as future physician. Initially, students were very much focused on medical problem solving. Completing the whole task of a consultation obligated them to transfer their theoretical medical knowledge into applicable clinical knowledge on the spot. Furthermore, diminishing the support of a supervisor triggered students to reflect on their own actions but contrasted with their increased appreciation of critical feedback. Increasing students' responsibility stimulated their active learning but made some students feel overloaded. These students were anxious to miss patient information or not being able to take the right decisions or to answer patients' questions, which sometimes resulted in evasive coping techniques, such as talking faster to prevent the patient asking questions. Conclusion: The complex task of conducting complete consultations should be implemented early within medical curricula because students need time to organize their medical knowledge into applicable clinical knowledge. An integrated consultation course should comprise a step-by-step teaching strategy with a variety of supervisors' feedback modi, adapted to students' competence. Finally, students should be guided in formulating achievable standards to prevent them from feeling overloaded in practicing complete consultations with simulated or real patients

Wound dressings for a proteolytic-rich environment

Wound dressings have experienced continuous and significant changes over the years based on the knowledge of the biochemical events associated with chronic wounds. The development goes from natural materials used to just cover and conceal the wound to interactive materials that can facilitate the healing process, addressing specific issues in non-healing wounds. These new types of dressings often relate with the proteolytic wound environment and the bacteria load to enhance the healing. Recently, the wound dressing research is focusing on the replacement of synthetic polymers by natural protein materials to delivery bioactive agents to the wounds. This article provides an overview on the novel protein-based wound dressings such as silk fibroin keratin and elastin. The improved properties of these dressings, like the release of antibiotics and growth factors, are discussed. The different types of wounds and the effective parameters of healing process will be reviewed

Factors confounding the assessment of reflection: a critical review

BACKGROUND: Reflection on experience is an increasingly critical part of professional development and lifelong learning. There is, however, continuing uncertainty about how best to put principle into practice, particularly as regards assessment. This article explores those uncertainties in order to find practical ways of assessing reflection. DISCUSSION: We critically review four problems: 1. Inconsistent definitions of reflection; 2. Lack of standards to determine (in)adequate reflection; 3. Factors that complicate assessment; 4. Internal and external contextual factors affecting the assessment of reflection. SUMMARY: To address the problem of inconsistency, we identified processes that were common to a number of widely quoted theories and synthesised a model, which yielded six indicators that could be used in assessment instruments. We arrived at the conclusion that, until further progress has been made in defining standards, assessment must depend on developing and communicating local consensus between stakeholders (students, practitioners, teachers, supervisors, curriculum developers) about what is expected in exercises and formal tests. Major factors that complicate assessment are the subjective nature of reflection's content and the dependency on descriptions by persons being assessed about their reflection process, without any objective means of verification. To counter these validity threats, we suggest that assessment should focus on generic process skills rather than the subjective content of reflection and where possible to consider objective information about the triggering situation to verify described reflections. Finally, internal and external contextual factors such as motivation, instruction, character of assessment (formative or summative) and the ability of individual learning environments to stimulate reflection should be considered

Clinical Evaluation of Caudal Superficial Epigastric Axial Pattern Flap Reconstruction of Skin Defects in 10 Dogs (1989–2001)

Ten dogs with caudal superficial epigastric axial pattern flap reconstruction of extensive skin defects were reviewed. Nine dogs had complete survival of the flap. In one dog, a small area of necrosis occurred near the flap tip. Other complications included seroma formation (n=3), partial incisional dehiscence (n=3), flap edema (n=9), and bruising (n=7). Use of the caudal superficial epigastric axial pattern flap provided full-thickness skin coverage of extensive skin defects of the rear limb and inguinal region, with relatively minor complications that were amenable to conservative management.</jats:p

The Effect of Hallux Sesamoid Resection on the Effective Moment of the Flexor Hallucis Brevis

In this cadaver study, the functional significance of the hallux sesamoid bones was quantified by measuring the effective tendon moment arm (ETMA) of the flexor hallucis brevis (FHB) force. (The ETMA differs from the anatomic tendon moment arm in that ETMAs are determined by the experimentally measured moment of the tendon force, rather than by the actual location and orientation of the tendon pull in the joint.) The intact case was compared with three levels of progressive sesamoid resection: distal half of the medial sesamoid excised, entire medial sesamoid excised, and both the medial and lateral sesamoids excised. Five dorsiflexion angles of the metatarsophalangeal joint were tested, ranging from −10° to 50°. A known active load was applied to the FHB muscle of fresh frozen cadaver specimens while the corresponding resisting forces from three orthogonally mounted transducers were being recorded. Results showed that the ETMAs decreased significantly ( P &lt; .05) only with the excision of both sesamoids. The percent decrease in ETMA was smallest at dorsiflexion angles of −10° and 15° (4.3% and 2.4%, respectively) and largest at dorsiflexion angles of 25°, 35°, and 50° (29.2%, 22.4%, and 26.7%, respectively). The clinical significance of the results is that distal hemiresection of the medial sesamoid or full medial sesamoid excision is unlikely to appreciably compromise the effective mechanical advantage of the FHB muscle. However, this mechanical advantage may be profoundly diminished by excision of both hallux sesamoids.</jats:p

Evaluation of Sacroiliac Wedge Rotation to Increase Acetabular Ventroversion

SummaryTreatment of canine hip dysplasia (CHD) via triple pelvic osteotomy (TPO) is widely accepted as the treatment that best preserves the existing hip joint. TPO, however, has several important disadvantages. In an effort to avoid some of the difficulties associated with TPO an alternative method of creating acetabular ventroversion (AW) was sought. The purpose of this study was to explore the effects of placement of a wedge in the sacroiliac (SI) joint on A W and to compare this to the effect of TPO on A W . On one hemipelvis a 30° pelvic osteotomy plate was used for TPO. The contralateral hemipelvis had a 28° SI wedge inserted into the SI joint. Pre- and postsurgical radiographs of each pelvis were taken and the angular measurements were recorded. On average, the 28° SI wedge resulted in 20.9° of A W, the 30° canine pelvic osteotomy plate resulted in 24.9° A W . Significant differences were not found (p &gt;0.05) between the two techniques. Sacroiliac wedge rotation effectively creates A W and has several theoretical advantages when compared to TPO. The in vivo effects of sacroiliac wedge rotation should be studied in order to evaluate the clinical effect of the technique.Sacroiliac wedge rotation was tested as an alternative method to increase the angle of acetabular ventroversion. This technique effectively rotated the acetabulum and has several theoretical advantages when compared to triple pelvic osteotomy.</jats:p

MagFRET: the first genetically encoded fluorescent Mg2+ sensor

Abstract Magnesium has important structural, catalytic and signaling roles in cells, yet few tools exist to image this metal ion in real time and at subcellular resolution. Here we report the first genetically encoded sensor for Mg 2+ , MagFRET-1. This sensor is based on the high-affinity Mg 2+ binding domain of human centrin 3 (HsCen3), which undergoes a transition from a moltenglobular apo form to a compactly-folded Mg 2+ -bound state. Fusion of Cerulean and Citrine fluorescent domains to the ends of HsCen3, yielded MagFRET-1, which combines a physiologically relevant Mg 2+ affinity (K d = 148 mM) with a 50% increase in emission ratio upon Mg 2+ binding due to a change in FRET efficiency between Cerulean and Citrine. Mutations in the metal binding sites yielded MagFRET variants whose Mg 2+ affinities were attenuated 2-to 100-fold relative to MagFRET-1, thus covering a broad range of Mg 2+ concentrations. In situ experiments in HEK293 cells showed that MagFRET-1 can be targeted to the cytosol and the nucleus. Clear responses to changes in extracellular Mg 2+ concentration were observed for MagFRET-1-expressing HEK293 cells when they were permeabilized with digitonin, whereas similar changes were not observed for intact cells. Although MagFRET-1 is also sensitive to Ca 2+ , this affinity is sufficiently attenuated (K d of 10 mM) to make the sensor insensitive to known Ca 2+ stimuli in HEK293 cells. While the potential and limitations of the MagFRET sensors for intracellular Mg 2+ imaging need to be further established, we expect that these genetically encoded and ratiometric fluorescent Mg 2+ sensors could prove very useful in understanding intracellular Mg 2+ homeostasis and signaling