OBJECTIVES Direct observation is the foundation of assessment and learning in competency-based medical education (CBME). Despite its importance, there is significant uncertainty about how to effectively implement frequent and high-quality direct observation. This is particularly true in specialties where observation of nonprocedural skills is highly valued and presents unique challenges. It is therefore important to understand perceptions of direct observation to ensure successful acceptance and implementation. In this study, we explored perceptions of direct observation in internal medicine.METHODS We interviewed internal medicine attending physicians (n = 9) and residents (n = 8) at the University of Toronto, purposively sampled for diversity. Using a constructivist grounded theory approach, constant comparative analysis was performed to develop a framework to understand perceptions of direct observation on the clinical teaching units. RESULTS Participants articulated a narrow perception of what constitutes directobservation, in contrast to their own descriptions of skills that were observed. This resulted in the perception that certain valuable skills that participants felt were routinely observed were nonetheless not 'directly observable', such as clinical reasoning, observed through case presentations and patient care discussions. Differentiating direct observation from informal observation led to overestimation of the time and resource requirements needed to enhance direct observation, which contributed to scepticism and lack of engagement related to CBME implementation.CONCLUSIONS In an internal medicine training programme, perceptions of what constitutes direct observation can lead to under-recognition and hinder acceptance in workplace-based assessment and learning. Our results suggest a reframing of 'direct observation' for residents and attending physicians, by explicitly identifying desired skills in non-procedurally-based specialties. These findings may help CBME-based training programmes improve the process of direct observation, leading to enhanced assessment and learning.

Levels of DNA, cholesterol, and phospholipids of mouse caudal epididymal and vas deferens sperm that were processed through simple washing and Percoll gradient centrifugation were measured. The DNA and cholesterol contents of washed sperm and Percoll gradient centrifuged (PGC) sperm (DNA = 3.6 +/- 0.3 pg/sperm and 3.4 +/- 0.3 pg/sperm, respectively; cholesterol = 0.219 +/- 0.057 nmole/microgram DNA and 0.224 +/- 0.030 nmole/microgram DNA, respectively, for washed and PGC sperm) were not significantly different from each other; however, the phospholipid level of PGC sperm was only one half of that of washed sperm (0.315 +/- 0.071 nmole/microgram DNA versus 0.720 +/- 0.075 nmole/microgram DNA, respectively). The presence of 0.3% bovine serum albumin (BSA) in the culture medium used in sperm washing did not change the cholesterol and phospholipid contents of washed sperm. Similarly, the cholesterol and phospholipid levels of washed sperm and PGC sperm that were further incubated in BSA-containing medium for 30 min remained the same. Interestingly, substantial amounts of lipids, as determined by the cholesterol and phospholipid levels, were released into the supernatants of the sperm washes, and sperm needed to be washed at least twice to ensure their stable levels of cholesterol and phospholipids. The lipid mixture in the first sperm wash supernatant was shown to have inhibitory effects on PGC sperm motility.

Levels of DNA, cholesterol, and phospholipids of mouse caudal epididymal and vas deferens sperm that were processed through simple washing and Percoll gradient centrifugation were measured. The DNA and cholesterol contents of washed sperm and Percoll gradient centrifuged (PGC) sperm (DNA = 3.6 ± 0.3 pg/sperm and 3.4 ± 0.3 pg/sperm, respectively; cholesterol = 0.219 ± 0.057 nmole/μg DNA and 0.224 ± 0.030 nmole/μg DNA, respectively, for washed and PGC sperm) were not significantly different from each other; however, the phospholipid level of PGC sperm was only one half of that of washed sperm (0.315 ± 0.071 nmole/μg DNA versus 0.720 ± 0.075 nmole/μg DNA, respectively). The presence of 0.3% bovine serum albumin (BSA) in the culture medium used in sperm washing did not change the cholesterol and phospholipid contents of washed sperm. Similarly, the cholesterol and phospholipid levels of washed sperm and PGC sperm that were further incubated in BSA‐containing medium for 30 min remained the same. Interestingly, substantial amounts of lipids, as determined by the cholesterol and phospholipid levels, were released into the supernatants of the sperm washes, and sperm needed to be washed at least twice to ensure their stable levels of cholesterol and phospholipids. The lipid mixture in the first sperm wash supernatant was shown to have inhibitory effects on PGC sperm motility. © 1996 Wiley‐Liss, Inc.

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