Should trainee doctors use the developing world to gain clinical experience? The annual Varsity Medical Debate - London, Friday 20th January, 2012

Mobile apps to self-manage chronic low back pain: A realist synthesis exploring what works, for whom and in what circumstances

Objective

Chronic low back pain places a significant burden on healthcare services and sufferers. Clinical guidelines state that it is a condition that requires self-management. This realist synthesis explores how a mobile app could help people to self-manage chronic low back pain.

Method

Six databases and several non-academic sources were searched. In addition, nineteen realist interviews were conducted with stakeholders. Sources were selected and appraised for relevancy, richness, and rigour. Data was coded with analytical memos making retroductive inferences. Causal explanations were presented in context-mechanism-outcome configurations to form three programme theories.

Results

Data from 57 sources was synthesised to create 16 context-mechanism-outcome configurations and presented as three refined programme theories. The findings suggest people need to feel believed before they will engage with a self-management app. For those who feel abandoned by the healthcare service, a self-management app for chronic low back pain can be a valuable source of ongoing support and reduce feelings of social isolation.

Conclusion

A self-management app, if introduced appropriately and as adjunct to care, can be an empowering tool to self-manage chronic low back pain.

Innovation

Using input from key stakeholders enhances our understanding of the hidden generative mechanisms underpinning a programme's success or failure.

A questionnaire study of the negative outcomes for UK health professional volunteers in low and middle income countries

INTRODUCTION

Past research has reported considerable benefits of international health professional volunteering for British healthcare professionals; however, there are also some negative outcomes reported. Negative outcomes reportedly happen on a personal, professional and organisational level. However, there is little evidence of the frequency they might occur.

METHODS

We aimed to understand what the negative outcomes of health professional volunteering in low-income and middle-income countries were, and how frequently they occurred, in an opportunistic sample of UK health professionals. We used a questionnaire developed using potential negative outcomes reported in the peer-reviewed papers. We conducted secondary analysis on cross-sectional questionnaire data from 222 healthcare professionals.

RESULTS

This research provides an indication of the frequency that negative outcomes might occur. Post hoc analyses revealed that some outcomes were experienced by the majority of health professional volunteers, for example, lack of formal recognition (131/169, 78%) and financial cost (92/169, 68%). While others happened less, for example, a reliance on agency or locum work (12/169, 7%) and loss of pension (31/169, 18%).

CONCLUSION

The outcomes reported in this research quantify some of the concerns that have been raised in previous literature. Negative outcomes might be associated with certain features of volunteering and further research is needed to prospectively compare different features. Organisers of volunteering opportunities should be aware of the potential negative outcomes and engage with the research into negative outcomes to generate and apply findings about minimising potential negative outcomes, carefully balancing these against the needs of the host country.

The benefits of international volunteering in a low-resource setting: development of a core outcome set

BACKGROUND

Qualitative narrative analysis and case studies form the majority of the current peer-reviewed literature about the benefits of professional volunteering or international placements for healthcare professionals. These often describe generalised outcomes that are difficult to define or have multiple meanings (such as 'communication skills' or 'leadership') and are therefore difficult to measure. However, there is an interest from employers, professional groups and individual volunteers in generating metrics for monitoring personal and professional development of volunteers and comparing different volunteering experiences in terms of their impact on the volunteers. In this paper, we describe two studies in which we (a) consolidated qualitative research and individual accounts into a core outcome set and (b) tested the core outcome set in a large group of global health stakeholders.

METHOD

We conducted a systematic review and meta-synthesis of literature to extract outcomes of international placements and variables that may affect these outcomes. We presented these outcomes to 58 stakeholders in global health, employing a Delphi method to reach consensus about which were 'core' and which were likely to be developed through international volunteering.

RESULTS

The systematic review of 55 papers generated 133 unique outcomes and 34 potential variables. One hundred fifty-six statements were then presented to the Delphi stakeholders, of which they agreed 116 were core to a wide variety of healthcare professional practice and likely to be developed through international experiences. The core outcomes (COs) were both negative and positive and included skills, knowledge, attitudes and outcomes for healthcare organisations.

CONCLUSIONS

We summarised existing literature and stakeholder opinion into a core outcome set of 116 items that are core to healthcare professional practice and likely to be developed through international experiences. We identified, in the literature, a set of variables that could affect learning outcomes. The core outcome set will be used in a future study to develop a psychometric assessment tool.

Ethical reflection for medical electives

BACKGROUND

Forty per cent of UK medical students undertake their elective in a developing country. Although these opportunities are often rewarding, students encounter ethical questions, both in preparation and undertaking these projects. The British Medical Association highlights three key ethical considerations for elective students: clinical challenges, cultural challenges and impact on the host institution. This report reflects on these considerations in the context of a 4-week medical elective conducted by UK medical students in the Solomon Islands.

METHODS

Daily interviews were conducted with a focus group of six medical students in the Solomon Islands over a 4-week elective period. Descriptive analysis identified key themes.

FINDINGS

Students were aware of guidelines stating that they must act within their competency, but found it difficult to assess their own skills and capacities in unfamiliar non-UK settings. Culturally different societal and medical norms proved particularly challenging. The impact of the student elective on the host hospital was also larger than anticipated.

DISCUSSION

In UK medical education, formal assessment sets the benchmark for competency. Assessments cannot cover every situation encountered on elective, and so students must therefore develop an alternative benchmark to measure their ability. The lack of research into the impact of electives on host institutions makes assessing the ethical nature of electives challenging. The British Medical Association highlights three key ethical considerations for elective students CONCLUSION: Prospective elective students would benefit from pre-departure training on self-assessment of competency and cultural awareness. UK medical schools have an ethical duty to encourage students to consider the impact of their elective placements on host institutions.

Tackling challenges of global health electives: Resident experiences of a structured and supervised medicine elective within an existing global health partnership

BACKGROUND

The Toronto-Addis Ababa Academic Collaboration in Emergency Medicine (TAAAC-EM) deploys teaching teams of Canadian EM faculty to Addis Ababa to deliver a longitudinal residency curriculum. Canadian trainees participate in these teams as a formally structured and supervised elective in global health (GH) and EM, which has been designed to enhance the strength of GH electives and address key challenges highlighted in the literature.

METHODS

The purpose of this qualitative study was to identify, describe, and evaluate strengths and weaknesses of this elective in relation to its purposeful structure. Residents who completed the elective were invited to participate in face-to-face interviews to discuss their experiences.

RESULTS

The findings show that the residents both chose this elective because of its purposefully designed features, and that these same features increased their enjoyment and the educational benefit of the elective. Supervised bedside teaching, relationships shared with Ethiopian residents, and the positive impact the experience had on their clinical practice in Canada were identified as the primary strengths.

CONCLUSION

Purposeful and thoughtful design of global health electives can enhance the resident learning experience and mitigate challenges for trainees seeking global health training opportunities.

Twelve tips to revitalise problem-based learning

The role of the problem-based learning (PBL) facilitator has seen different interpretations ever since PBL first gained widespread use. What has remained unchanged is the challenge for facilitators to use their knowledge and expertise sparingly and to use their interpersonal skills to improve group dynamics. Medical undergraduates attending PBL sessions have also changed in their skill sets, expectations and the use of technology. Based on the published literature and a recent faculty workshop, we provide PBL facilitators and institutions with 12 tips on how to make PBL more vibrant and interesting. We discuss our tips with reference to published literature and International Academy of Medical Education (AMEE) guidance. Our tips help students to engage with PBL, avoid monotony and make this teaching format more vibrant and fun for all involved. Introducing greater variety to the PBL process may also help with group dynamics by catering for a broader audience with different learning styles.

Teaching corner: "first do no harm": teaching global health ethics to medical trainees through experiential learning

Recent studies show that returning global health trainees often report having felt inadequately prepared to deal with ethical dilemmas they encountered during outreach clinical work. While global health training guidelines emphasize the importance of developing ethical and cultural competencies before embarking on fieldwork, their practical implementation is often lacking and consists mainly of recommendations regarding professional behavior and discussions of case studies. Evidence suggests that one of the most effective ways to teach certain skills in global health, including ethical and cultural competencies, is through service learning. This approach combines community service with experiential learning. Unfortunately, this approach to global health ethics training is often unattainable due to a lack of supervision and resources available at host locations. This often means that trainees enter global health initiatives unprepared to deal with ethical dilemmas, which has the potential for adverse consequences for patients and host institutions, thus contributing to growing concerns about exploitation and "medical tourism." From an educational perspective, exposure alone to such ethical dilemmas does not contribute to learning, due to lack of proper guidance. We propose that the tension between the benefits of service learning on the one hand and the respect for patients' rights and well-being on the other could be resolved by the application of a simulation-based approach to global health ethics education.