Doctor performance assessment in daily practise: does it help doctors or not? A systematic review

CONTEXT: Continuous assessment of individual performance of doctors is crucial for life-long learning and quality of care. Policy-makers and health educators should have good insights into the strengths and weaknesses of the methods available. The aim of this study was to systematically evaluate the feasibility of methods, the psychometric properties of instruments that are especially important for summative assessments, and the effectiveness of methods serving formative assessments used in routine practise to assess the performance of individual doctors. METHODS: We searched the MEDLINE (1966-January 2006), PsychINFO (1972-January 2006), CINAHL (1982-January 2006), EMBASE (1980-January 2006) and Cochrane (1966-2006) databases for English language articles, and supplemented this with a hand-search of reference lists of relevant studies and bibliographies of review articles. Studies that aimed to assess the performance of individual doctors in routine practise were included. Two reviewers independently abstracted data regarding study design, setting and findings related to reliability, validity, feasibility and effectiveness using a standard data abstraction form. RESULTS: A total of 64 articles met our inclusion criteria. We observed 6 different methods of evaluating performance: simulated patients; video observation; direct observation; peer assessment; audit of medical records, and portfolio or appraisal. Peer assessment is the most feasible method in terms of costs and time. Little psychometric assessment of the instruments has been undertaken so far. Effectiveness of formative assessments is poorly studied. All systems but 2 rely on a single method to assess performance. DISCUSSION: There is substantial potential to assess performance of doctors in routine practise. The longterm impact and effectiveness of formative performance assessments on education and quality of care remains hardly known. Future research designs need to pay special attention to unmasking effectiveness in terms of performance improvement.     

Ameloblastoma: current etiopathological concepts and management

Ameloblastoma is a benign odontogenic tumor of epithelial origin. It is locally aggressive with unlimited growth capacity and has a high potential for malignant transformation as well as metastasis. Ameloblastoma has no established preventive measures although majority of patients are between ages 30 and 60 years. Molecular and genetic factors that promote oncogenic transformation of odontogenic epithelium to ameloblastoma are strongly linked to dysregulation of multiple genes associated with mitogen‐activated protein kinase, sonic hedgehog, and WNT/β‐catenin signaling pathways. Treatment of ameloblastoma is focused on surgical resection with a wide margin of normal tissue because of its high propensity for locoregional invasion; but this is often associated with significant patient morbidity. The relatively high recurrence rate of ameloblastoma is influenced by the type of molecular etiological factors, the management approach, and how early the patient presents for treatment. It is expected that further elucidation of molecular factors that orchestrate pathogenesis and recurrence of ameloblastoma will lead to new diagnostic markers and targeted drug therapies for ameloblastoma.     

How do short-term rates of femorotibial cartilage change compare to long-term changes? Four year follow-up data from the osteoarthritis initiative

OBJECTIVE: To compare unbiased estimates of short- vs long-term cartilage loss in osteoarthritic knees. METHOD: 441 knees [216 Kellgren Lawrence (KL) grade 2, 225 KL grade 3] from participants of the Osteoarthritis Initiative were studied over a 4-year period. Femorotibial cartilage thickness was determined using 3?T double echo steady state magnetic resonance imaging, the readers being blinded to time points. Because common measurement time points bias correlations, short-term change (year-1 to year-2: Y1?→?Y2) was compared with long-term change (baseline to year-4: BL?→?Y4), and initial (BL?→?Y1) with subsequent (Y2?→?Y4) observation periods. RESULTS: The mean femorotibial cartilage thickness change (standardized response mean) was?-1.2%/-0.8% (-0.42/-0.28) over 1 (BL?→?Y1/Y1?→?Y2),?-2.1%/-2.5% (-0.56/-0.55) over 2 (BL?→?Y2/Y2?→?Y4),?-3.3% (-0.63) over 3 (Y1?→?Y4), and?-4.5% (-0.78) over 4 years. Spearman correlations were 0.33 for Y1?→?Y2 vs BL?→?Y4, and 0.17 for BL?→?Y1 vs Y2?→?Y4 change. Percent agreement between knees showing progression during Y1?→?Y2 vs BL?→?Y4 was 59%, and 64% for BL?→?Y1 vs Y2?→?Y4. The area under the receiver operating characteristic curve was 0.66 for using Y1?→?Y2 to predict BL?→?Y4, and 0.59 for using BL?→?Y1 to predict Y2?→?Y4 change. CONCLUSION: Weak to moderate correlations and agreement were observed between individual short- vs long-term cartilage loss, and between initial and subsequent observation periods. Hence, longer observation periods are recommended to achieve robust results on cartilage loss in individual knees. At cohort and subcohort level (e.g., KLG3 vs KLG2 knees), the mean cartilage loss increased almost linearly with the length of the observation period and was constant throughout the study.     

The ethics of psychopharmacological research in legal minors

Research in psychopharmacology for children and adolescents is fraught with ethical problems and tensions. This has practical consequences as it leads to a paucity of the research that is essential to support the treatment of this vulnerable group. In this article, we will discuss some of the ethical issues which are relevant to such research, and explore their implications for both research and standard care. We suggest that finding a way forward requires a willingness to acknowledge and discuss the inherent conflicts between the ethical principles involved. Furthermore, in order to facilitate more, ethically sound psychopharmacology research in children and adolescents, we suggest more ethical analysis, empirical ethics research and ethics input built into psychopharmacological research design.