The Dinarides‐Hellenides result from underthrusting of the Adriatic margin during Africa‐Europe convergence. In Albania, they consist of (1) a western zone of nappes derived from Adria; (2) a central ...belt made up of the Mirdita ophiolites; and (3) an eastern zone, the Korabi‐Pelagonia zone, of Variscan basement overlain by Permian to Mesozoic rift deposits and carbonates. Some authors interpret the Korabi‐Pelagonia zone as a microcontinent between the Mirdita‐Pindos oceanic basin to the west and the eastern Vardar oceanic basin to the east; other regard the Korabi‐Pelagonia zone as a tectonic window below a single ophiolitic nappe. This contribution argues for a far‐traveled thrust sheet. The Mirdita ophiolites are 165–160 Ma. The metamorphic sole yielded 40Ar/39Ar ages of 171 to 162 Ma. The Korabi‐Pelagonia zone is subdivided into the Korabi and Gjegjan subzones. The structural analysis of these rocks supports the rooting of the Mirdita ophiolites in the Western Vardar zone. The post‐Variscan cover sequence of the Korabi subzone records two phases of deformation: D1 is associated with a SE dipping to flat‐lying schistosity axial planar to NW verging folds and thrust faults, related to ophiolite obduction; D2 is a postobduction NNE trending crenulation cleavage. Published zircon fission track analyses yielded 150–125 Ma, suggesting that regional metamorphism is Early Cretaceous or older. K‐Ar mica ages from correlative rocks of Macedonia cluster between 148 and 130 Ma, indicating that D1 is Late Jurassic. A west directed obduction is favored, as is a rooting east of the Mirdita ophiolites because of the top‐to‐the‐west structural polarity of obduction‐related deformation.
Key Points
Structures of the Korabi zone shows that the ophiolite roots in the Vardar zone
Obduction is Late Jurassic, consistent with ages of the metamorphic sole
The obduction history lasted, within errors, for (less than or equal to) 20 Myr
Introduction
Evaluation of poorly performing physicians is a worldwide concern for licensing bodies. The Collège des Médecins du Québec currently assesses the clinical competence of physicians ...previously identified with potential clinical competence difficulties through a day‐long procedure called the Structured Oral Interview (SOI). Two peer physicians produce a qualitative report. In view of remediation activities and the potential for legal consequences, more information on the clinical reasoning process (CRP) and quantitative data on the quality of that process is needed. This study examines the Script Concordance Test (SCT), a tool that provides a standardized and objective measure of a specific dimension of CRP, clinical data interpretation (CDI), to determine whether it could be useful in that endeavor.
Methods
Over a 2‐year period, 20 family physicians took, in addition to the SOI, a 1‐hour paper‐and‐pencil SCT. Three evaluators, blind as to the purpose of the experiment, retrospectively reviewed SOI reports and were asked to estimate clinical reasoning quality. Subjects were classified into 2 groups (below and above median of the score distribution) for the 2 assessment methods. Agreement between classifications is estimated with the use of the Kappa coefficient.
Results
Intraclass correlation for SOI was 0.89. Cronbach alpha coefficient for the SCT was 0.90. Agreement between methods was found for 13 participants (Kappa: 0.30, P = 0.18), but 7 out of 20 participants were classified differently in both methods. All participants but 1 had SCT scores below 2 SD of panel mean, thus indicating serious deficiencies in CDI.
Discussion
The finding that the majority of the referred group did so poorly on CDI tasks has great interest for assessment as well as for remediation. In remediation of prescribing skills, adding SCT to SOI is useful for assessment of cognitive reasoning in poorly performing physicians. The structured oral interview should be improved with more precise reporting by those who assess the clinical reasoning process of examinees, and caution is recommended in interpreting SCT scores; they reflect only a part of the reasoning process.
Peer-assessment processes with chart review have been used for many years to assess the clinical performance of physicians. The Quebec medical licensing authority has been required by provincial law ...to assess the practicing Quebec physicians on a nonvoluntary basis. During the period from January 2001 to November 2004, 25 family physicians in active practice were randomly selected from a pool of about 300. For each physician, 25 to 40 patients' medical charts were randomly selected to evaluate the interrater reliability of peer-review assessment of medical charts and to compare ratings based on chart review with a chart-stimulated recall interview to those based on chart review alone. The concordance between chart review alone and that of chart review with chart-stimulated recall interview was 75% for chart keeping, 69% for clinical investigation, 81% for diagnostic accuracy, and 74% for treatment plan. Ratings based on chart review alone achieve moderate levels of reliability (Kappa = 0.44 to 0.56). It appears that some important information about quality of care is missed when only chart review is used.
To evaluate the link between the quantity and quality of continuing professional development (CPD) activities completed by family physicians in Quebec and the quality of their practice.
Retrospective ...analysis of data collected during professional inspection visits (PIVs).
Quebec.
Three groups were created from among Quebec family physicians who had been subject to PIVs (peer evaluation) by the Collège des médecins du Québec between 1998 and 2005. Group 1 was composed of physicians who were members of the College of Family Physicians of Canada, which requires participation in 250 hours of CPD in every 5-year cycle. Group 2 was composed of family physicians who were not members of the College of Family Physicians of Canada but who had declared at least 50 hours a year of CPD on their Collège des médecins du Québec annual notice of assessment for the same period. Group 3 was composed of family physicians who had declared fewer than 10 hours of CPD a year.
During the PIV, the following characteristics were examined: record keeping, quality and number of hours of CPD activities, and quality of professional practice based on 3 components- clinical investigation, accuracy of diagnosis, and appropriateness of treatment plan and follow-up.
The factors associated with a high quality of practice were privileges in a hospital or local community health centre (institution) and a substantial number of accredited CPD hours (Mainpro-M1, Credit I, or Mainpro-C). The factors associated with a poor quality of practice were advanced age of the physician, absence of privileges in an institution (hospital or local community health centre), and participation in CPD activities that were more informal, such as reading and non-accredited activities (Mainpro-M2).
This study supports earlier research showing that CPD activities of sufficient quality and quantity are correlated with a high quality of professional practice by family physicians.
In many countries, peer assessment programs based on the examination of patient charts are becoming a standard to assess physician’s clinical performance. Although data on validity of the process are ...acceptable, reliability issues need some improvement. This article addresses the rarely studied aspect of optimal number of patient charts for an acceptable reliable assessment. Fifteen patient charts for each of a group of 20 practicing physicians were independently reviewed by 4 professional peer assessors. Generalizability (G) and decision (D) studies were applied to the data. It appears that as few as 10 patient charts are sufficient for any assessor to obtain a G coefficient of 0.80. Results of the current study suggest the possibility of getting generalizable assessments by peer reviewer with minimal information. These results are not in accordance with the concept of case specificity in which it is claimed that performance on a case is a poor predictor of performance on a different case.
On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict ...accessibility, continuity, and coordination of care as experienced by patients.
Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic.
One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office.
The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.
Introduction: The Collège des médecins du Québec (CMQ) offers an individualized remedial professional development program to help physicians overcome selected clinical shortcomings. To measure the ...influence of the remedial professional development program, physicians who completed the program between 1993 and 2004 and who were assessed by peer review during a 2‐year period preceding or following the remedial activities were tracked.
Methods: For each physician, 30 to 50 patient records were selected randomly for review. Ratings were assigned for the quality of record keeping and for 3 elements pertaining to the quality of care: the clinical investigation plan, diagnostic accuracy, and patient treatment and follow‐up. The impact of the program was measured by comparing the proportion of physicians with satisfactory ratings assigned by peer review before and after the remedial professional development program.
Results: Statistically significant improvements (p < .05) were observed for a proportion of physicians (n = 51) with satisfactory ratings with regard to record keeping (20% before and 54% after remediation), the clinical investigation plan (13% before and 59% after remediation), diagnostic accuracy (32% before and 61% after remediation), and patient treatment and follow‐up (31% before and 67% after remediation).
Discussion: Participation in a CMQ remedial professional development program can result in improved clinical performance, as assessed through peer review.
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