Clinical Competence in ST-segment Elevation Myocardial Infarction Management by Recently Graduated Physicians Applying for a Medical Residency Program

Abstract Background: A significant reduction in the morbidity and mortality related to ST-segment elevation myocardial infarction (STEMI) has been achieved with the development of reperfusion therapies. Early diagnosis and correct initial management are important to ensure this benefit. In Brazil, recent graduates in medicine are responsible for a large part of the initial care provided for these patients. Objective: To assess the clinical competence in the diagnosis and initial treatment of STEMI by newly graduated physicians applying for a medical residency program. Methods: We assessed the performance of 771 applicants for the direct entry selection process of the FMRP-USP Clinical Hospital Medicine Residency Program, performed in a simulated setting of STEMI, with professional actors and medical evaluators, using a standardized checklist following the recommendations of the Brazilian Guidelines for the management of this disease. Results: The general performance score presented a median of 7 and an interquartile range of 5.5-8.0. In relation to the items assessed: 83% required ECG monitoring, 57% requested the insertion of a peripheral venous access catheter, 95% administered acetylsalicylic acid, 80% administered a second antiplatelet agent (p2y12 inhibitor), 66% administered nitrate, 71% administered morphine, 69% recognized the diagnosis of STEMI, 71% assessed the pain duration, 63% recognized the need for immediate transfer, 34% showed adequate communication skills and only 25% insisted on the transfer even in case of non-availability of beds. Conclusions: The initial diagnosis and management of STEMI need to be improved in medical undergraduate courses and inserted into the reality of the hierarchical network structure of the Brazilian Unified Health System (SUS).

摘要
背景：随着再灌注治疗技术的发展，与ST段抬高型心肌梗死（ST-segment elevation myocardial infarction，STEMI）相关的发病率与死亡率已得到显著降低。早期诊断与规范的初始处置是保障该治疗获益的核心前提。在巴西，医学专业应届毕业生承担了此类患者初始救治的绝大多数工作。
研究目的：评估申请住院医师规范化培训项目的应届医学毕业生在ST段抬高型心肌梗死诊断与初始治疗方面的临床胜任能力。
研究方法：纳入771名申请FMRP-USP临床医院内科住院医师直接招录选拔流程的申请者，在由专业演员与医学考官参与的ST段抬高型心肌梗死模拟诊疗场景中，采用遵循巴西该病诊疗指南推荐意见的标准化核查表对其表现进行评估。
研究结果：整体表现得分的中位数为7，四分位间距为5.5~8.0。针对各评估项目的统计结果显示：83%的申请者需进行心电监护，57%申请置入外周静脉通路导管，95%给予乙酰水杨酸（阿司匹林）治疗，80%给予第二种抗血小板药物（P2Y12抑制剂），66%给予硝酸酯类药物，71%给予吗啡治疗，69%能够正确识别ST段抬高型心肌梗死的诊断，71%评估了疼痛持续时间，63%意识到需立即转诊，仅34%具备恰当的沟通能力，且仅有25%在床位不足的情况下仍坚持转诊。
研究结论：巴西医学本科教育需加强ST段抬高型心肌梗死的初始诊断与处置相关教学，并将相关内容融入巴西统一卫生系统（SUS）层级化医疗网络的实际诊疗场景中。