Residents who participated in the FC demonstrated improved QI knowledge compared with the control group. Residents valued the in-class application sessions more than the online component. These findings have important implications for graduate medical education as residency training programs increasingly use FC models.

Introduction: Learners may subconsciously change their behavior once they know they are being observed, and this Hawthorne effect should be considered when designing assessments of learner behavior. While there is a growing body of literature to suggest direct observation is the ideal standard for formative assessment, the best method to directly observe learners is unknown. We explored scheduled and unscheduled methods of direct observation among internal medicine residents in the outpatient continuity clinic to advance the understanding of both observation methods. Methods: We conducted a thematic analysis of faculty and internal medicine residents in an outpatient clinic setting. A semi-structured interview guide for focus group sessions was created. Focus groups were used to explore the internal medicine resident and core teaching faculty perceptions of the scheduled and unscheduled direct observation methods in the outpatient clinc. An experienced qualitative research interviewer external to the internal medicine residency was moderating the sessions. Eight peer focus groups were held. Abstraction of themes from focus group transcripts identified resident and faculty perceptions of the different observation methods. Results: Focus groups had 14 resident participants and 14 faculty participants. Unscheduled observations were felt to be more authentic than scheduled observations since residents perceived their behavior to be unmodified. Unscheduled observations allowed for increased numbers of observations per resident, which permitted more frequent formative assessments. Residents and faculty preferred remote video observation compared to in-room observation. Participants found direct observation a useful learning tool for high-yield, specific feedback. Conclusions: Unscheduled remote direct observation captures authentic clinical encounters while minimizing learner behavior modification. An unscheduled observation approach results in more frequent formative assessment and therefore in more instances of valuable feedback compared to scheduled observations. These findings can help guide the best practice approaches to direct clinical observation in order to enhance residents learning and experience.

Shoulder pain is a common occurrence after spinal cord injury (SCI) and can have significant negative effects on health and function as many individuals with SCI are reliant on their upper extremities for mobility and self-care activities. Shoulder pain after SCI can be caused by acute injury or chronic pathology, but it is most often related to overuse injuries of the rotator cuff. Both acute strain and chronic overuse shoulder injuries in persons with SCI typically result from increased weight bearing on the upper extremities during transfers, weight-relief raises, and wheelchair propulsion, which are often performed in poor postural alignment owing to strength deficits. This article discusses management of patients with SCI who present with shoulder pain from the perspective of primary care physicians including evaluation and diagnostic procedures, interventions appropriate for both acute and chronic shoulder pain, and strategies for prevention.

16-year-old boy presented to his primary care physician because of a 13.5-kg unintentional weight gain, acne, and new-onset hypertension with systolic blood pressure in the range of 170 mm Hg over several months. Review of systems was positive for fatigue, intermittent epigastric pain, polydipsia, polyuria, and nocturia. His medical history included iron deficiency anemia of unknown etiology, treated with oral iron replacement therapy. On examination, the patient was afebrile with a blood pressure of 137/84 mm Hg and a heart rate of 83 beats/min. Skin examination revealed severe acne on the face, chest, and back. His face was round and plethoric. There was moderate centripetal obesity with purple striae on the arms, thighs, and abdomen. The remainder of his examination findings were within normal limits. Laboratory studies yielded unremarkable results (reference ranges provided parenthetically), except for a serum potassium concentration of 2.7 mmol/L (3.6-5.2 mmol/L) and a fasting plasma glucose concentration of 122 mg/dL (70-100 mg/dL). A complete blood cell count demonstrated microcytic anemia.