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COMMENTARYOSCE: The subjective experience of an objective examAlim Nagji, BHScMedical Student (2012), Faculty of Medicine and Dentistry, University of Alberta, Edmonton, CanadaCorrespondence to Alim Nagji, Email: anagji@ualberta.caAbstractThe Objective Structured Clinical Examination (OSCE) is theprimary modality for testing clinical skills throughout medicalschool and in residency training. This article explores the difficultiesof the exam via the subjective perspective of a student in thesystem, commenting on reticent standardized patients, the lackof consensus on what makes an ideal medical student and theabsence of feedback. As the exam celebrates nearly four decades inuse, it is important that we continue to evaluate its usefulness andbrainstorm innovative approaches to advancing the state of clinicalexaminations.The Objective Structure Clinical Examination (OSCE) has rapidlybecome the leading clinical examination in North American MedicalSchools. The unassailable champion of repetitive and reproducibleevaluation, it has become the envy of all other tests. While multiplechoice still holds a prominent position in most medical curricula,that is usually for the convenience of administering the test and thesheer volume of information one can sift through. As a learner, onehas had ample time to exploit the system, mastering the nuances ofthe “all of the following EXCEPT” and “which answer is the BEST”questions. In reality, we have been asked this type of question sincekindergarten and the PBS specials we grew up on sang “one of thesethings is not like the other one.” 1The OSCE is succinctly explained in the abstract of a 1975 BMJ article:“the examination is more objective and a marking strategy can bedecided in advance.” 2 The veracity of the latter half of this requirementis evidenced by the rubric style approach of many modern OSCEs.However, the first part is where the interesting dilemma lies. Is theexamination more objective? From the subjective experience ofstudents, it would hardly seem so.The variability lies in the innate qualities of both the “standardizedpatient” and the examiner. Having worked as a standardized patient,the instructions one often receives is to be as guarded as possibleabout information, refraining from volunteering details unlessspecifically probed. This is in direct contrast to the guidance offeredin basic history taking skills, where students are counselled to allowthe patient to convey the narrative of their illness uninterrupted. Forthose that have participated in OSCEs, it is easy to recall those actorsfrom whom information had to be stolen as if it were precious gems.From many a station I have walked out and, in conversation withmy peers in different tracks, realized that another “standardized”patient had been much more forthcoming with a pivotal piece of thediagnostic puzzle.In Rowntree’s 17 proposals for better assessment, he notes that“there is an assumption rampant in talk of academic standards,that all qualified assessors feel, understand and judge in much thesame way when confronted with the work of a particular student.It is presumed that they would notice and value the same skills andqualities and would broadly agree in their assessments. Abundantevidence attests to the falsity of such assumptions.” 3 In the sameway, examiners vary widely in their preferences of what they believemakes the ideal learner. One need only glance at the complicatedmedical admission system or the behemoth that is the CanadianResident Matching Service (CaRMS) to realize that we cannot agreeon the perfect model student, yet we continue to cling to antiquatedstandards so as to maintain a united front. Despite the broadaccusations suggesting poor inter-rater reliability across a varietyof domains, 4 OSCE examinations remain a mainstay of evaluationdespite their artificial construction and potentially variableenvironment.In the same seminal article, the authors proclaim that the“examination results in improved feed-back to students and staff.” 2This may hold true for the teaching OSCEs, where 2 minutes ofpersonalized commentary follows each station, but for the majorityof exams in medicine, the results are protected and not released. Sowhile occasionally one may receive a grade or score sheet, one isleft waiting for the commentary that can enhance clinical skills orrefine an approach. The majority of instructors emphasize the needto train physicians, not test takers, yet the very nature of receiving apass or a fail undermines the learning process. Research has shownthat overall, detailed, descriptive feedback was found to be mosteffective when given alone, unaccompanied by grades or praise, thedirect opposite of what students usually receive. 5 The OSCE hassignificant advantages over multiple choice questions, providing arich opportunity for students to simulate patient encounters andmaintain some degree of standardization. However, it’s limitationsand shortcomings should be discussed, rather than disputed. Themodern OSCE, nearly 40 years after its rise to prominence, seemsstagnant in the face of the rapid change in the medical community.Perhaps as we enter a new decade of medical education we cancritique our instruments, as well as our students, and developinnovative models to evaluate competence in clinical skills.1. Cooney, J.G. (creator). Seasame Street [Television Series]. New York:PBS 1969.2. Harden, R. McG. Stevenson, M., Downie, W.W. & Wilson, G.M.Assessment of clinical competence using objective structuredexaminations. British Medical Journal 1975;I: 447.3. Rowntree, D. Assessing students: how shall we know them?London: Kogan Page 1977. As cited in: Harden, R., Gleeson, F.A.Assessment of clinical competence using an objective structuredclinical examination (OSCE). Medical Education 1979;13(1):39-54.4. Thistlethwaite, JE. Developing an OSCE station to assess theability of medical students to share information and decisionswith patients: issues relating to interrater reliability and the use ofsimulated patients. Educ Health (Abingdon) 2002;15(2):170-9.5. Lipnevich, A.A., Smith, J.K. Response to assessment feedback: Theeffects of grades, praise and sources of information. Retrieved fromProQuest Digital Dissertations 2008; 3319438.2University of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1
University of Alberta Summer Students’ Research DayIn 2011, over 200 undergraduate students participated in the Faculty of Medicine & Dentistry Summer StudentResearch Program. On October 15, 175 students presented posters at the 44th Annual Summer Students’ ResearchDay. Listed below are the 14 finalists from the poster competition. We congratulate the finalists and all participants.RESEARCHFrom these 14 finalists, two students were selected to represent theUniversity of Alberta at the annual National Students’ ResearchForum in Galveston, Texas. Their abstracts are presented below.Uncovering the role of topoisomerase II-betabinding protein 1 in dna replication stress responseMark Assmus, Charles Leung, Mark GloverDNA replication stress can lead to genomic instability which hasbeen shown to be one of the primary hallmarks of cancer. TopBP1 is acrucial mediator protein found within the replication stress responsein mammalian cells. TopBP1 activates Ataxia telangiectasia mutatedrelated (ATR) kinase which phosphorylates many of the downstreamsubstrates to initiate this response. The replication stress responseinvolves specific interactions between the nine BRCA1 C terminus(BRCT) domains of TopBP1 and various proteins. More specifically,TopBP1 has been shown to provide an essential role in interactingwith both ATR-interacting protein (ATRIP), Rad9-Rad1-Hus1 (9-1-1)complex as well as Mediator of DNA damage checkpoint protein 1(MDC1) which are all essential components of the response pathway.The crystal structure of TopBP1 BRCT 4/5 in complex with MDC1 waspreviously solved in our lab. The structure shows a unique mode ofTopBP1 binding to MDC1 that involves the dimerization of two BRCT4/5 molecules. In an effort to further examine this interaction, I useda fluorescence polarization (FP) binding assay involving an MDC1FITC labelled di-phospho-peptide. I was able to express and purifyGST fusion proteins of TopBP1 BRCT 4/5 and TopBP1 BRCT 5, as wellas TopBP1 BRCT 5 alone, which were used for further FP studies.The results of the FP assays indicated that it is the BRCT 5 bindingpocket which is primarily responsible for the interaction with MDC1and that the dimerization induced by GST allows for tighter binding.Additionally, mutant constructs of the putative BRCT 5 bindingpocket were designed, successfully over-expressed and purified.The FP assays showed decreases in binding affinity associated withmutation of key conserved residues in the binding pocket. FP wasalso used to confirm that the phosphorylation of the MDC1 peptideis essential for TopBP1 BRCT 4/5 recognition. Taken together, theseFP results further support the unique dimerization-based bindingmechanism suggested by the crystal structure.PAX3 expression in melanomaZachary Tan and D. Alan UnderhillThe transcription factor PAX3 is critical for development of neuralcrest lineages including melanocytes. Prior to birth, PAX3 isrequired for the proliferation of melanocyte precursors and it isthought to maintain an ‘undifferentiated plastic state’ in epidermalmelanocytes after birth, as well in melanocyte stem cells. Inaddition, PAX3 is expressed throughout melanoma progression,from nevi to metastatic disease. Nevertheless, little is known abouthow PAX3 carries out these diverse roles. PAX3 is reported to bephosphorylated by Glycogen Synthase Kinase 3ß (GSK3ß). In thepresent study, the potential role of this kinase in modulating PAX3activity in B16F10 melanoma cells was examined using chemicalinhibitors. Fluorescence Activated Cell Sorting (FACS) was usedto assess cell cycle distribution and PAX3 levels were monitoredby immunoblotting. Treatment of cells with the GSK3ß inhibitorslithium chloride (LiCl) or BIO caused decreased cell proliferation(P=0.05) and G2/M accumulation (P=0.05), and was associatedwith increased PAX3 expression (P=0.05). In contrast, knockdownof PAX3 using siRNA resulted in G1 accumulation (P=0.05).Immunofluorescence techniques for exogenous BrdU incorporationand endogenous PS10H3 allowed for direct microscopic visualizationand quantification of cells in S and G2/M phase respectively. UponPAX3 knockdown, there was significantly less BrdU incorporationand PS10H3 staining (P=0.05). Lastly, cell motility assays wereconducted using live-cell Differential Interference Contrast (DIC)microscopy and analyzed using T-Scratch software. Interestingly,inhibition of GSK3ß as well as PAX3 knockdown was associatedwith markedly decreased cellular motility and proliferation. Theseinvestigations identify GSK3ß and as an important modulator ofPAX3 levels in melanoma cells, and also suggest broader roles forPAX3 in regulating the G1 to S-phase transition in melanoma.Student Poster Title SupervisorMark AssmusChristopherBeavingtonAlannaChomynNicholas ChuaAlexandruCojocaruMichelinaKierzekStephanie MahScott MeyerRobyn MillottKian ParseyanAmit PersadRaheemSulemanUncovering the role of topoisomerase II-betabinding protein 1 in DNA replication stressresponseThe structural studies of bacterial lactoferrinbinding protein B from Neisseria meningitidesIsolation of trkA expressing and IB4-bindingsensory neurons through the use of saporinA model system for complex redox enzymematurationUsing inhibition of protein N-myristoylationtowards the design of a synthetically lethaltreatment of B-cell lymphomasElucidating the molecular mechanismsof heart disease-linked mutations ofphospholambanCapase 1 Inhibition in inflammatory boweldisease reduces epithelial cell extrusionInvestigating the quinone binding site ofEscherichia coli fumarate reductaseThe novel interaction betweenN-myristoyltransferase 1 and calnexinProposed improvements for intraspinalmicrostimulation array fabrication andinsertionExpression of ST8Sia family in developingchick retina and their role in AP2deltamediatedaxonal generationDoes long life come from mom? Isolation ofa longevity-conferring mitochondrial DNAmutation in Caenorhabditis elegansDr. Mark GloverDr. Joanne LemieuxDr. Christine WebberDr. Joel H. WeinerDr. Luc G.BerthiaumeDr. Howard S. YoungDr. Julia LiuDr. Joel H. WeinerDr. Marek MichalakDr. Vivian K.MushahwarDr. Roseline GodboutDr. Bernard D.LemireDepartment/DivisionBiochemistryBiochemistryAnatomyBiochemistryCell BiologyBiochemistryMedicine/GastroenterologyBiochemistryBiochemistryCell BiologyOncologyBiochemistryZachary Tan PAX3 expression in melanoma Dr. Alan Underhill OncologyTerri WallerPartial deficiency of adipose trigylceridelipase (atgl) does not protect againstdiabetes-induced cardiac dysfunctionDr. Jason R.B. DyckPediatricsUniversity of Alberta Health Sciences Journal • April 2012 • Volume 7 • Issue 1 3
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