RESUMEN

BACKGROUND: If continuing professional development is to work and be sensible, an understanding of clinical practice is needed, based on the daily experiences of doctors within the multiple factors that determine the nature and quality of practice. Moreover, there must be a way to link performance and assessment to ensure that ongoing learning and continuing competence are, in reality, connected. Current understanding of learning no longer holds that a doctor enters practice thoroughly trained with a lifetime's storehouse of knowledge. Rather a doctor's ongoing learning is a 'journey' across a practice lifetime, which involves the doctor as a person, interacting with their patients, other health professionals and the larger societal and community issues. OBJECTIVES: In this paper, we describe a model of learning and practice that proposes how change occurs, and how assessment links practice performance and learning. We describe how doctors define desired performance, compare actual with desired performance, define educational need and initiate educational action. METHOD: To illustrate the model, we describe how doctor performance varies over time for any one condition, and across conditions. We discuss how doctors perceive and respond to these variations in their performance. The model is also used to illustrate different formative and summative approaches to assessment, and to highlight the aspects of performance these can assess. CONCLUSIONS: We conclude by exploring the implications of this model for integrated medical services, highlighting the actions and directions that would be required of doctors, medical and professional organisations, universities and other continuing education providers, credentialling bodies and governments.

Asunto(s)

Asunto(s)

RESUMEN

The clinical competence of physicians depends largely on the education, accreditation, certification and licensing programs offered by the various Canadian medical organizations. In virtually all of these, doctor-patient communication is a required element. Educational programs at all levels are subject to accreditation by a number of different organizations including undergraduate medical programs (Committee on Accreditation of Canadian Medical Schools), residency training (College of Family Physicians of Canada and Royal College of Physicians and Surgeons of Canada) and continuing medical education (CFPC and RCPSC). Doctor-patient communication is a key element in teaching at all levels. The two colleges also emphasize communications in the certification process. The provincial licensing authorities are aware of the importance of effective communication between physicians and patients. Several of the them have physician assessment programs, and recently they have started to assess a model of mandatory performance review. Both of these approaches assess physician-patient communication. There is increasing pressure, with strong support from consumers, that some level of communication skills competency should be imposed by the licensing authorities. Most approaches to exposing physicians to communications focus on rewards rather than coercion but a number of possible schemes could be considered to promote communication skills.

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)

RESUMEN

Since 1987, McGill University's Department of Family Medicine has invited new faculty to an orientation workshop. Workshop topics cover learning agreements and principles of adult learning, effective teaching methods, and feedback and evaluation. Workshop methods aim to promote active participation and experiential learning.

Asunto(s)

RESUMEN

We examined how adult children in Canada whose parents were hospitalized in an acute care setting perceived responsibility for their parents' care. Using a visual analogue scale, adult children rated the amount of financial, emotional, and physical support families "should" and "could" give to elderly persons described in four vignettes. All scores were high, with "should" consistently higher than "could" for every vignette and for each of the three types of support. For daughters, the more aggressive the parent, the lower the "should" score for financial support. The same relationship was observed for incontinence and these findings were consistent over all four vignettes.

Asunto(s)

RESUMEN

This paper describes the use of innovative teaching techniques in clinical teaching. Advantages proposed include increasing teacher and learner enthusiasm, improving participation and developing techniques that are most appropriate to learning goals. Examples of different innovative techniques are provided which are grouped into the categories of experiential learning, role-playing, competition and games, stimulus materials, brain-storming and sub-grouping. Finally, practical guidelines to develop and utilize innovations are suggested. The use of innovative techniques requires time, planning, a commitment to the teaching process and a belief that the resulting learning will be both more enjoyable and productive.

Asunto(s)

RESUMEN

The certification examination of the College of Family Physicians of Canada is designed to assess the extent to which the College's educational objectives have been achieved. Since the first examination in 1969, more than 7000 physicians have received their certification. The authors describe the basic elements of this test and the process through which the Committee on Examinations designs and sets the examination. The authors comment on the role of the certification process in the education of family physicians in Canada.

RESUMEN

Falls in the elderly constitute a major problem confronting physicians. Their cost to individual patients and to society in terms of incidence, morbidity, and mortality is enormous. This paper attempts to outline some of the common etiological factors related to falls and a practical approach to the diagnosis and management. Causes of falls are clssified as extrinsic and intrinsic factors. The latter include disorders of many organ systems, especially those resulting from neurological and cardiovascular diseases. The role of drugs and alcohol is stressed. Determining the cause of falls requires a thorough history and physical examination. In order to manage successfully an elderly person with multiple falls, a co-ordinated effort by a multi-disciplinary team is often essential.

RESUMEN

A randomized, double-blind, placebo-controlled trial was conducted with 32 elderly patients (aged 75-97 years) with uncomplicated essential hypertension, to evaluate the efficacy and tolerance of enalapril, an angiotensin-converting enzyme inhibitor. It was given over an 8-week period in doses from 20 to 40 mg/day and was compared with an identical placebo. Enalapril caused a significant reduction in systolic blood pressure (SBP) and diastolic blood pressure (DBP) by the 2nd week, an effect that persisted through to the 8th week (190 +/- 16/102 +/- 7 to 151 +/- 19/85 +/- 11 mm Hg); 67% of patients had their pressures normalized (less than 160/95 mm Hg). BP was also significantly decreased by the 8th week under placebo (183 +/- 16/101 +/- 9 to 165 +/-21/91 +/- 13 mm Hg), but only 35% of patients attained a normal pressure. Heart rate did not change with treatment. Enalapril caused an increase in plasma renin activity (1.22 +/- 0.08 to 3.66 +/- 2.50 ng/ml/h), whereas aldosterone levels remained unchanged. There was a mild, significant elevation of creatinine level with enalapril but other laboratory parameters, including serum potassium, were unaltered. Two deaths occurred in the enalapril group, but were not considered to be treatment-related. The drug was otherwise well tolerated. Serum enalapril concentration was assessed in 10 patients taking 20 mg/day over an 8-day period. At equilibrium, the level was 22.3 +/- 5.0 ng/l and it correlated both with converting enzyme inhibition and with renal function. Enalapril is shown to be an effective and well-tolerated antihypertensive medication in elderly patients.

Asunto(s)

RESUMEN

The purpose of this study was to investigate the effectiveness and safety of enalapril in elderly people. A double-blind, randomized, placebo-controlled trial was carried out in 32 subjects aged from 75 to 97 years (mean: 86 years) with blood pressure values equal or superior to 160/90 mmHg. After 8 weeks of treatment with enalapril in doses of 20 to 40 mg/day, the systolic pressure was lowered from 190 +/- 16 to 151 +/- 19 mmHg (P less than 0.0001) and the diastolic pressure from 102 +/- 7 to 85 +/- 11 mmHg (P less than 0.0001). Systolic and diastolic pressures were also significantly reduced in subjects under placebo (from 183 +/- 16 to 165 +/- 21 mmHg, P less than 0.001; and from 101 +/- 9 to 91 +/- 13 mmHg, P less than 0.001, respectively), but the degree of reduction was significantly superior with enalapril (systolic: 39 +/- 25 vs 18 +/- 19 mmHg, P less than 0.005; diastolic: 17 +/- 13 vs 11 +/- 12, P less than 0.001); blood pressure was inferior to 160/90 mmHg in 67% of the subjects treated, as against 35% of those under placebo. Two patients under enalapril died: one on the 27th, the other on the 47th day of treatment. No relation could be established between these deaths and the drug, and this figure of 2 is not significantly different for the number of deaths expected over the same period in a population of that age-group. Among the patients under placebo, one had pulmonary embolism on the 34th day and another had a sudden increase in blood pressure on the 6th day, requiring discontinuation of treatment. It is concluded that enalapril administered alone is effective and well tolerated. Long-term studies are needed to find out whether this angiotensin-converting enzyme inhibitor is superior to a diuretic as initial treatment of arterial hypertension.

Asunto(s)

Asunto(s)

Asunto(s)

Asunto(s)