The new final Clinical Skills examination in human medicine in Switzerland: Essential steps of exam development, implementation and evaluation, and central insights from the perspective of the national Working Group.

OBJECTIVE: Since 2011, the new national final examination in human medicine has been implemented in Switzerland, with a structured clinical-practical part in the OSCE format. From the perspective of the national Working Group, the current article describes the essential steps in the development, implementation and evaluation of the Federal Licensing Examination Clinical Skills (FLE CS) as well as the applied quality assurance measures. Finally, central insights gained from the last years are presented. METHODS: Based on the principles of action research, the FLE CS is in a constant state of further development. On the foundation of systematically documented experiences from previous years, in the Working Group, unresolved questions are discussed and resulting solution approaches are substantiated (planning), implemented in the examination (implementation) and subsequently evaluated (reflection). The presented results are the product of this iterative procedure. RESULTS: The FLE CS is created by experts from all faculties and subject areas in a multistage process. The examination is administered in German and French on a decentralised basis and consists of twelve interdisciplinary stations per candidate. As important quality assurance measures, the national Review Board (content validation) and the meetings of the standardised patient trainers (standardisation) have proven worthwhile. The statistical analyses show good measurement reliability and support the construct validity of the examination. Among the central insights of the past years, it has been established that the consistent implementation of the principles of action research contributes to the successful further development of the examination. CONCLUSION: The centrally coordinated, collaborative-iterative process, incorporating experts from all faculties, makes a fundamental contribution to the quality of the FLE CS. The processes and insights presented here can be useful for others planning a similar undertaking.

Gefäßchirurgische Ausbildung in endovaskulärer Technik in Lausanne

Between 1995 and 2005, the number of aortic aneurysms treated annually using endovascular techniques (EVAR) increased from 0 to 50, including all aortic stages. Our organization includes a large team of surgeons, a stock of three complete families of endoprostheses (straight, conical and bifurcated), a mobile trolley with accessories (arterial introducer/introducer sheath, guide wire, catheters, balloons, etc.) and an appliance on wheels for intravascular ultrasound examination (IVUS). This appliance, together with a mobile fluoroscopy device (c-arm), allows endovascular aneurysms analysis of every operating room in our institution, usually without angiography or the use of contrast medium. In general, we are therefore not depending on substantial preoperative imaging in order to identify candidates for endovascular aneurysms repair and can treat abdominal and thoracic aortic ruptures without delay. For endovascular aortic aneurysms repair we distinguish between process steps on the one hand (determining indications, imaging of the access vessels, measurement using IVUS and road mapping via fluoroscopy, selection of implant, implant insertion, positioning, setting the implant, determining success, reconstruction of the access vessel and follow-up) and the level of competence on the other (assistant, senior and directing physicians). Our ultrasound supported technique for endovascular aneurysms repair has been successfully brought to other hospitals using an IVUS transporter and telementoring.

La résistance bactérienne aux antibiotiques.

50 years ago, the introduction of penicillin, followed by many other antibacterial agents, represented an often underestimated medical revolution. Indeed, until that time, bacterial infections were the prime cause of mortality, especially in children and elderly patients. The discovery of numerous new substances and their development on an industrial scale gave us the illusion that bacterial infections were all but vanquished. However, the widespread and sometimes uncontrolled use of these agents has led to the selection of bacteria resistant to practically all available antibiotics. Bacteria utilize three main resistance strategies: (1) modification of their permeability, (2) modification of target, and (3) modification of the antibiotic. Bacteria modify their permeability either by becoming impermeable to antibiotics, or by actively excreting the drug accumulated in the cell. As an alternative, they can modify the structure of the antibiotic's molecular target--usually an essential metabolic enzyme of the bacterium--and thus escape the drug's toxic effect. Lastly, they can produce enzymes capable of modifying and directly inactivating antibiotics. In addition, bacteria have evolved extremely efficient genetic transfer systems capable of exchanging and accumulating resistance genes. Some pathogens, such as methicillin-resistant Staphylococcus aureus and multiresistant Mycobacterium tuberculosis, have become resistant to almost all available antibiotics and there are only one or two substances still active against such organisms. Antibiotics are very precious drugs which must be administered to patients who need them. On the other hand, the development of resistance must be kept under control by a better comprehension of its mechanisms and modes of transmission and by abiding by the fundamental rules of anti-infectious chemotherapy, i.e.: (1) choose the most efficient antibiotic according to clinical and local epidemiological data, (2) target the bacteria according to the microbiological data at hand, and (3) administer the antibiotic in an adequate dose which will leave the pathogen no chance to develop resistance.