Examining the nexus between medical education and complexity: a systematic review to inform practice and research

BACKGROUND

Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory ('complexity') signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research.

METHODS

A structured literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A narrative and thematic synthesis was undertaken to create a deep understanding of the use of complexity in medical education.

RESULTS

Eighty-three papers were included; the majority were conceptual papers. The context and theoretical underpinnings of complexity as a relevant theory for medical education were identified. Bibliographic and temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as a theoretical framework for empirical studies covering a variety of elements within medical education including: knowledge and learning theories; curricular, program and faculty development; program evaluation and medical education research; assessment and admissions; professionalism and leadership; and learning for systems, about systems and in systems.

DISCUSSION

There is a call for greater use of theory by medical educators. Complexity within medical education is established, although not widespread. Individualistic cultures of medicine and comfort with reductionist epistemologies challenges its introduction. However, complexity was found to be a useful theory across a range of areas by a limited number of authors and is increasingly used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research.

CONCLUSION

This literature review can assist in understanding how complexity can be useful in medical educationalists' practice.

Using Household Consumption Data to Flag Low Nutrient Access

BACKGROUND

Information on food consumption, dietary diversity, and nutrient inadequacies are key for informing food security and nutrition programming. Household- and individual-level data together provide the most complete information, but individual dietary modules are not always feasible in humanitarian contexts due to cost and time constraints.

OBJECTIVE

This article asks to what extent it is possible to use food consumption data which is commonly collected at household level through food security and vulnerability surveys, to assess the household's access to vitamin A and iron.

METHODS

The validation analysis uses household food consumption and expenditure surveys from Guatemala, Honduras, Nepal, and Uganda and the adult male equivalent approach for calculating nutrient access.

RESULTS

The results show a positive significant correlation between the frequency of consumption and adequacy as estimated from comprehensive household food consumption modules, with correlation in the range of 0.4 to 0.7. Frequency thresholds for distinguishing between adequate and inadequate nutrient access, based on how often foods rich in the relevant nutrient are eaten during 1 week, mostly fulfill standard sensitivity and specificity criteria.

CONCLUSIONS

The article concludes that in humanitarian contexts, a frequency-based proxy for nutrient access based on household data commonly collected in emergency assessments and through monitoring systems can be used and can support this particular data gap. As a rule of thumb, a frequency threshold of 7 should be used for vitamin A and of 12 for iron.

The effectiveness of leucocyte-poor platelet-rich plasma injections on symptomatic early osteoarthritis of the knee: the PEAK randomized controlled trial

AIMS

Platelet-rich plasma (PRP) intra-articular injections may provide a simple and minimally invasive treatment for early-stage knee osteoarthritis (OA). This has led to an increase in its adoption as a treatment for knee OA, although there is uncertainty about its efficacy and benefit. We hypothesized that patients with early-stage symptomatic knee OA who receive multiple PRP injections will have better clinical outcomes than those receiving single PRP or placebo injections.

METHODS

A double-blinded, randomized placebo-controlled trial was performed with three groups receiving either placebo injections (Normal Saline), one PRP injection followed by two placebo injections, or three PRP injections. Each injection was given one week apart. Outcomes were prospectively collected prior to intervention and then at six weeks, three months, six months, and 12 months post-intervention. Primary outcome measures were Knee Injury and Osteoarthritis Outcome Score (KOOS) and EuroQol five-dimension five-level index (EQ-5D-5L). Secondary outcomes included visual analogue scale for pain and patient subjective assessment of the injections.

RESULTS

A total of 102 patients were recruited. The follow-up period was 12 months, at intervals of six weeks, 12 weeks, six months, and 12 months. KOOS-Total significantly improved in all groups at these time intervals compared to pre-injection. There was an improvement in EQ-5D-5L index scores in saline and single injection groups, but not in the multiple injection group. Comparison of treatment groups showed no additional beneficial effect of single or multiple PRP injections above that displayed in the saline injection group. Subjective patient satisfaction and recommendation of treatment received demonstrated a similar pattern in all the groups. There was no indication of superiority of either single or multiple PRP injections compared to saline injections.

CONCLUSION

There is no evidence that single or multiple PRP had any additional beneficial effect compared to saline injection up to 12 months, follow-up after treatment of early stage symptomatic OA of the knee. Cite this article: Bone Joint J 2022;104-B(6):663-671.

Medical Students' and Trainees' Country-By-Gender Profiles: Hofstede's Cultural Dimensions Across Sixteen Diverse Countries

Purpose

The global mobility of medical student and trainee populations has drawn researchers' attention to consider internationalization in medical education. Recently, researchers have focused on cultural diversity, predominately drawing on Hofstede's cross-cultural analysis of cultural dimensions from general population data to explain their findings. However, to date no research has been specifically undertaken to examine cultural dimensions within a medical student or trainee population. This is problematic as within-country differences between gender and professional groups have been identified within these dimensions. We address this gap by drawing on the theoretical concept of national context effects: specifically Hofstede's six-dimensional perspective. In doing so we examine medical students' and trainees' country profiles across dimensions, country-by-gender clustering, and differences between our data and Hofstede's general population data.

Methods

We undertook a cross-cultural online questionnaire study (eight languages) containing Hofstede's 2013 Values Survey. Our questionnaire was live between 1st March to 19th Aug 2018, and December 2018 to mitigate country holiday periods. We recruited undergraduate medical students and trainees with at least 6-months' clinical training using school-specific methods including emails, announcements, and snowballing.

Results

We received 2,529 responses. Sixteen countries were retained for analyses (n = 2,307, 91%): Australia, Chile, China, Hong Kong, India, Indonesia, Ireland, Israel, Japan, Malaysia, New Zealand, Pakistan, South Africa, South Korea, Sri-Lanka, Taiwan. Power distance and masculinity are homogenous across countries. Uncertainty avoidance shows the greatest diversity. We identified four country clusters. Masculinity and uncertainty are uncorrelated with Hofstede's general population data.

Conclusions

Our medical student and trainee data provides medical education researchers with more appropriate cultural dimension profiles than those from general population data. Country cluster profiles stimulate useful hypotheses for further research, especially as patterning between clusters cuts across traditional Eastern-Western divides with national culture being stronger than gendered influences. The Uncertainty dimension with its complex pattern across clusters is a particularly fruitful avenue for further investigation.

Attributes and generic competencies required of doctors: findings from a participatory concept mapping study

BACKGROUND

Medical education should ensure graduates are equipped for practice in modern health-care systems. Practicing effectively in complex health-care systems requires contemporary attributes and competencies, complementing core clinical competencies. These need to be made overt and opportunities to develop and practice them provided. This study explicates these attributes and generic competencies using Group Concept Mapping, aiming to inform pre-vocational medical education curriculum development.

METHODS

Group Concept Mapping is a mixed methods consensus building methodology whereby ideas are generated using qualitative techniques, sorted and grouped using hierarchical cluster analysis, and rated to provide further quantitative confirmation of value. Health service providers from varied disciplines (including medicine, nursing, allied health), health profession educators, health managers, and service users contributed to the conceptual model's development. They responded to the prompt 'An attribute or non-clinical competency required of doctors for effective practice in modern health-care systems is...' and grouped the synthesized responses according to similarity. Data were subjected to hierarchical cluster analysis. Junior doctors rated competencies according to importance to their practice and preparedness at graduation.

RESULTS

Sixty-seven contributors generated 338 responses which were synthesised into 60 statements. Hierarchical cluster analysis resulted in a conceptual map of seven clusters representing: value-led professionalism; attributes for self-awareness and reflective practice; cognitive capability; active engagement; communication to build and manage relationships; patient-centredness and advocacy; and systems awareness, thinking and contribution. Logic model transformation identified three overarching meta-competencies: leadership and systems thinking; learning and cognitive processes; and interpersonal capability. Ratings indicated that junior doctors believe system-related competencies are less important than other competencies, and they feel less prepared to carry them out.

CONCLUSION

The domains that have been identified highlight the competencies necessary for effective practice for those who work within and use health-care systems. Three overarching domains relate to leadership in systems, learning, and interpersonal competencies. The model is a useful adjunct to broader competencies frameworks because of the focus on generic competencies that are crucial in modern complex adaptive health-care systems. Explicating these will allow future investigation into those that are currently well achieved, and those which are lacking, in differing contexts.

Exploring how differently patients and clinical tutors see the same consultation: building evidence for inclusion of real patient feedback in medical education

BACKGROUND

Undergraduate medical education recognises that patient feedback is potentially valuable for student learning and development as a component of multi-source feedback. However greater exploration of how patient feedback perspectives differ to clinical educators is required for curriculum development and improving student feedback literacy. This study aimed to determine how two sources of feedback, patients and clinical tutors, compare on the same patient-centred, interpersonal criteria.

METHODS

A patient feedback instrument designed for the undergraduate medical education setting was used to compare patients' feedback with clinical tutors' feedback following a student-patient consultation in the learning context. Assessments from 222 learning consultations involving 40 medical students were collected. Descriptive statistics for tutors and patients for each question were calculated and correlations between patient and tutor were explored using Spearman's rank-order correlation. Mixed effects ordered logistic regression was used to compare each question with an overall rating for tutor and patients in addition to comparing patient with tutor ratings.

RESULTS

Clinical tutor and patient assessments had a weak but significant positive correlation in all areas except questions related to respect and concern. When making judgements compared with overall assessment, patients' ratings of respect, concern, communication and being understood in the consultation have a greater effect. After eliminating the effect of generally higher ratings by patients compared with tutors using comparative ordered logistic regression, patients rated students relatively less competent in areas of personal interaction.

CONCLUSION

This study provides insight about patient feedback, which is required to continue improving the use and acceptability of this multisource feedback to students as a valuable component of their social learning environment. We have revealed the different perspective-specific judgement that patients bring to feedback. This finding contributes to building respect for patient feedback through greater understanding of the elements of consultations for which patients can discriminate performance.

Los teléfonos móviles como potencial vehículo de infección en un entorno hospitalario

ResumenEl objetivo de este artículo es investigar el posible papel desempeñado por los teléfonos móviles como depósitos de colonización bacteriana y los factores de riesgo que ésta conlleva en un ambiente hospitalario. Entre enero de 2013 y marzo de 2014 examinamos a 226 miembros del personal de un hospital regional de Australia (146 médicos y 80 estudiantes de medicina). Los principales resultados de interés se relacionaron con los tipos de microorganismos y la cantidad de contaminación encontrados en los teléfonos móviles. Este estudio mostró la existencia de un alto nivel de contaminación bacteriana (n = 168/226, 74%) en los teléfonos móviles de los funcionarios de un hospital de atención terciaria, aislándose organismos similares en la mano dominante del personal y en sus teléfonos móviles. Mientras que la mayoría de los organismos aislados pertenecía a la flora cutánea normal, un pequeño porcentaje era potencialmente patógeno (n = 12/226, 5%). Además, se encontró que ser miembro subalterno del personal médico constituía un factor de riesgo para un importante crecimiento microbiano (OR 4.00, 95% CI 1.54, 10.37). Sólo 31% (70/226) de los participantes en el estudio informó que limpiaba sus teléfonos regularmente y sólo 21% (47/226) reportó que usa toallitas con alcohol para la limpieza de su teléfono. Este estudio demuestra que los teléfonos móviles son potenciales vehículos de bacterias patógenas en un ambiente hospitalario. Sólo una minoría de participantes informó que limpia su teléfono regularmente. Deberían elaborarse y aplicarse directrices de desinfección utilizando toallitas con alcohol.

Termination of pregnancy in Tasmania: access and service provision from the perspective of GPs

Termination of pregnancy (TOP) is considered an important component of sexual and reproductive health internationally, but there are known barriers in Australia and countries worldwide. This study investigated the issues for GPs regarding aiding access to TOP and providing early medical abortion (EMA) services for Tasmanian women. Specifically, the aims of the study were to identify the knowledge and attitudes of Tasmanian GPs regarding TOP services and to determine which known barriers to providing EMA are most significant for GPs in Tasmania, Australia. A survey was developed and piloted based on previous qualitative research that identified known barriers to accessing TOP. Surveys were posted to all identified GPs in Tasmania with a reply-paid envelope. In all, 211 (27.4%) responses were returned. GPs identified difficulty accessing TOP services, particularly for rural women and those on a low income. Almost half the GPs, excluding conscientious objectors, indicated they would be interested in providing EMA services, but perceived barriers were significant. The most significant barriers related to accessing appropriate training and support. There was uncertainty around financial reward, support services, medical indemnity and access to the medical abortifacient medications mifepristone and misoprostol. In conclusion, accessing TOP remains an issue for Tasmanian women. Many Tasmanian GPs are interested in providing EMA services if barriers are addressed, but there is a lack of knowledge about the practicalities of implementing EMA. Providing practical support to GPs and increasing knowledge pertaining to EMA provision in general practice could improve access in primary care.

Engaging "hard-to-reach" men in health promotion using the OPHELIA principles: Participants' perspectives

ISSUE ADDRESSED

Men in the Northern Suburbs of Launceston, Tasmania, experience substantially poorer health outcomes and socio-economic disadvantage than most Australians. They are often described as "hard-to-reach," meaning difficult to engage in research, health promotion, policy and planning. This paper summarises the OPHELIA process to combine health literacy profiling with engagement of local men in health promotion, and their experience of the process and outcomes.

METHODS

Interviews were conducted to explore the experiences of middle-aged men with the OPHELIA process and subsequent interventions.

RESULTS

Local data and health literacy profiling revealed experiences of isolation, lack of trust in the system, medication non-adherence, mental illness and chronic pain, which formed the basis for generation of ideas to improve their well-being and understanding of health. Tailored interventions were implemented, including suicide prevention, "Numeracy for Life" and "Healthy Sheds" courses. Interviews with six participants revealed that the process contributed to a sense of worth, social support and ability to break "old habits."

CONCLUSIONS

Prioritising the lived experience of "hard-to-reach" men through the OPHELIA process resulted in co-design of interventions that were valued by participants. SO WHAT?: Health literacy profiling and genuine community engagement can empower vulnerable, under-represented communities to co-design, and engage in, health promotion.

A "messy ball of wool": a qualitative study of the dimensions of the lived experience of obesity

Background

Obesity is a multi-dimensional condition with causal factors beyond the physiological into the behavioural, dietetic and psychological. Understanding the lived experience of those who are overweight and obese and self-perceived barriers to access and engagement in intervention are imperative to formulating a systemic response to the complex problem of obesity. This study aims to identify the social, psychological and systemic factors impeding engagement with weight-loss behaviour and interventions, and to formulate a framework for responding to these.

Methods

We conducted an exploratory qualitative study using focus groups and interviews with people who have lived experienced of being overweight or obese. Data were analysed using an inductive thematic approach. Following the thematic analysis, further interpretation of the data was achieved by applying the epistemological foundations of the Lifeworld Led Care paradigm, recognising its philosophy of the person and of care based on the individual’s experiences. Eight men and 17 women participated.

Results

Three overarching themes were identified: Complexity and Battle, Impediments, and Positive Re-orientation. The subthemes of these were found to represent the dimensions of the Lifeworld: Identify, Inter-subjectivity, Mood and Embodiment.

Further interpretation of the themed data identified six polarised dichotomies representing the opposing lived dimensions of the obesity experience: Failure Double-Bind; Think-Feel Conflict; Negative-Positive Orientation; Impeding-Facilitating Health Professional; Knowledge as Deficit-Insight; and Internal-External Orientation.

Conclusion

Obesity manifests as constraints and challenges across six polarised dichotomies, active in the lived experience of obesity. This study provides a unique way of conceptualising and understanding the complex and interacting meanings of the lived experience of obesity through the construction of polarised dichotomies. The polarities signify the oscillating experiences that people with obesity encounter, which may be either helpful or destructive in both their lifeworld experience and their capacity to address obesity towards improved social, psychological and physical outcomes. Understanding the dichotomies allows a reconceptualisation of obesity from a quantification of the individual to a more respectful, humane, compassionate and utilitarian conceptualisation of the experiencing person and the phenomenon itself. Further, these lived polarised dichotomies of obesity present the opportunity for health professionals to reconceptualise obesity in care and interventions.

Leveraging an Implementation– Research Partnership to Improve Effectiveness of Nutrition-Sensitive Programs at the World Food Programme

Background:

Nutrition-sensitive programs can accelerate progress in addressing malnutrition. However, evidence gaps exist related to their effectiveness and how to optimize program design and implementation.

Objective:

We present the process the International Food Policy Research Institute and the World Food Programme (WFP) used to develop nutrition-sensitive program guidance and plans for improving program effectiveness and contributing to the evidence base through rigorous evaluations.

Methods:

A 5-step process, using principles of design thinking (a systematic, iterative analytical approach to problem solving), was used to develop, test, and refine WFP’s nutrition-sensitive guidance. The guidance focuses on improving nutrition outcomes for nutritionally vulnerable groups across the life cycle: women and children in the first 1000 days, preschoolers, schoolchildren, and adolescents.

Results:

Through iterative consultations, we created WFP’s nutrition-sensitive guidance that includes harmonized theories of change across WFP’s programs; 7 opportunities to enhance the programs’ nutrition-sensitivity; and mapping of these opportunities to WFP programs and key evidence gaps. This guidance has been rolled out to WFP’s offices worldwide to support improved nutrition outcomes. Finally, several evaluation designs have been proposed to fill identified evidence gaps.

Conclusions:

By leveraging our implementation–research partnership, we expect that WFP’s programs will be more effective and cost effective for improving nutrition. This can be assessed through coupling newly designed nutrition-sensitive programs with rigorous evaluations. Evaluation results will be used to refine WFP’s nutrition-sensitive guidance and improve their programs globally. This guidance, and creation process, could be useful for others interested in designing nutrition-sensitive programs and increasing program effectiveness for nutrition.

A mental health programme for medical students

BACKGROUND

It is critical that medical educators actively address the growing mental health burden affecting medical students. The motivation to present a mental health programme to medical students at the University of Tasmania arose in response to a recent tragedy within the student body. This emphasised the necessity of developing an effective skill-based initiative for our students. We describe a peer-led programme targeting mental health borne from this event. The aim of this article is to outline the development of this programme and to report on the preliminary feedback.

METHODS

This article presents a peer-led programme, delivered to medical students in the fourth year of a 5-year undergraduate degree by peers from within the student cohort. We used a multipronged approach, with the programme consisting of a five-session workshop and a supplementary resource book. A post-workshop survey was administered as formative evaluation. A total of 19 out of 20 participants responded to the survey.

RESULTS AND DISCUSSION

All respondents agreed that the programme helped to reduce the stigma of mental health disease in medicine and improved both peer support and self-care practices. All students agreed that they would recommend this programme to peers, and that it provided a welcome opportunity to talk about mental health and normalised mental health concerns. Key to the success of the programme was its peer-led nature. The programme is an example of an innovative and effective programme design that can help to guide medical educators to further support the next generation of medical practitioners with their mental health skills. Our focus was on building practical skills for students to support their own and others' mental health.

Mixed-method evaluation of a community-wide physical activity program in Launceston, Australia

ISSUE ADDRESSED

Physical inactivity is a leading risk factor for disease burden and premature mortality. Interventions to increase physical activity are common, though few examples of multi-strategy, wide-scale community programs exist. Active Launceston is a community-wide program aimed at improving health and well-being through physical activity. We report on the process evaluation of Active Launceston and changes in community physical activity participation between 2008 and 2015, as a measure of program effectiveness.

METHODS

Mixed-method evaluation of Active Launceston combined process evaluation-consisting of participant numbers, socio-demographic characteristics, campaign awareness, focus groups and stakeholder interviews-with impact evaluation consisting of a random-sample cross-sectional serial telephone survey.

RESULTS

Active Launceston attracted 11 887 attendees, participating in 30 342 sessions, amounting to 38 088 hours of physical activity between 2008 and 2015. Participant focus groups highlighted benefits including increased engagement in exercise, better health and social connectedness. While telephone surveys found the proportion of people participating in any physical activity in the last 12 months to be similar between the 3 years (2008, 77.7%; 2012, 77.1%; 2015, 73.6%), a higher proportion participated in vigorous physical activity in 2012 and 2015 compared to 2008 (P < 0.01), when adjusting for age and gender differences. A higher proportion also achieved sufficient activity for health in 2015 compared to 2008 (P = 0.01).

CONCLUSIONS

Mixed-method evaluation suggests Active Launceston is an effective community-wide program supporting community members to engage in regular physical activity and increase levels of social engagement. SO WHAT?: This work provides a model for implementing high-reach, community-wide interventions that improve physical activity outcomes.

Diagnosis and management of chronic hip and knee pain in a Tasmanian orthopaedic clinic: a study assessing the diagnostic and treatment planning decisions of an advanced scope physiotherapist

The aim of this study is to investigate the clinical effectiveness of an advanced practice physiotherapist triaging patients referred from primary care to the orthopaedic clinic with chronic hip and knee pain. An exploratory study design was used to assess 87 consecutive patients referred from general practice in Northern Tasmania. Patients were assessed by both an advanced practice physiotherapist and a consultant orthopaedic surgeon. Diagnostic and treatment decisions were compared, with the orthopaedic consultant decision defined as the gold standard. By using these decisions, over and under referral rates to orthopaedics could be calculated, as well as the surgical conversion rate. Conservative care of patients referred to the orthopaedic clinic with hip and knee pain was limited. The diagnostic agreement between the advanced scope physiotherapist and the orthopaedic surgeon was almost perfect (weighted kappa 0.93 (95% CI 0.87–1.00)), with treatment agreement substantial (weighted kappa 0.75 (95% CI 0.62–0.89)). Under a physiotherapist-led triage service, the surgical conversion rate doubled from 38% to 78%. An advanced physiotherapist assessing and treating patients with chronic hip and knee pain made decisions that match substantially with decisions made by an orthopaedic consultant. A model of care utilising an advanced physiotherapist in this way has the potential to support high-quality orthopaedic care in regional centres.

Does Dexamethasone Reduce Hospital Readiness for Discharge, Pain, Nausea, and Early Patient Satisfaction in Hip and Knee Arthroplasty? A Randomized, Controlled Trial

BACKGROUND

Reduction in postoperative pain, nausea, and vomiting in patients undergoing total joint arthroplasty may facilitate earlier discharge from hospital and reduce healthcare costs. This study was performed to primarily assess whether perioperative dexamethasone reduced hospital length of stay and to assess the effect on pain, nausea and vomiting, and patient satisfaction.

METHODS

One hundred sixty-four patients undergoing total hip arthroplasty or total knee arthroplasty were randomized to receive either 8 mg intravenous dexamethasone (n = 86) or placebo (n = 78) at induction and at 24 hours postsurgery. The primary outcome was length of stay and secondary outcomes were pain and nausea visual analog scale scores, analgesic and antiemetic usage, blood glucose level, and patient satisfaction.

RESULTS

Participants in the study group achieved earlier readiness for discharge. There was a 20% reduction in pain scores and morphine usage was 27% lower in the study group. Nausea scores were similar in the 2 groups but there was lower antiemetic usage in the study group. Satisfaction scores at 6 weeks postsurgery in the dexamethasone group were significantly higher than the placebo group. There was no difference in complication rates between the 2 groups.

CONCLUSION

The administration of intravenous dexamethasone could lead to earlier readiness for discharge especially in patients undergoing elective total hip arthroplasty, primarily by a reduction in postoperative pain scores and/or morphine requirements.

Determining requirements for patient-centred care: a participatory concept mapping study

BACKGROUND

Recognition of a need for patient-centred care is not new, however making patient-centred care a reality remains a challenge to organisations. We need empirical studies to extend current understandings, create new representations of the complexity of patient-centred care, and guide collective action toward patient-centred health care. To achieve these ends, the research aim was to empirically determine what organisational actions are required for patient-centred care to be achieved.

METHODS

We used an established participatory concept mapping methodology. Cross-sector stakeholders contributed to the development of statements for patient-centred care requirements, sorting statements into groupings according to similarity, and rating each statement according to importance, feasibility, and achievement. The resultant data were analysed to produce a visual concept map representing participants' conceptualisation of patient-centred care requirements. Analysis included the development of a similarity matrix, multidimensional scaling, hierarchical cluster analysis, selection of the number of clusters and their labels, identifying overarching domains and quantitative representation of rating data.

RESULTS

The outcome was the development of a conceptual map for the Requirements of Patient-Centred Care Systems (ROPCCS). ROPCCS incorporates 123 statements sorted into 13 clusters. Cluster labels were: shared responsibility for personalised health literacy; patient provider dynamic for care partnership; collaboration; shared power and responsibility; resources for coordination of care; recognition of humanity - skills and attributes; knowing and valuing the patient; relationship building; system review evaluation and new models; commitment to supportive structures and processes; elements to facilitate change; professional identity and capability development; and explicit education and learning. The clusters were grouped into three overarching domains, representing a cross-sectoral approach: humanity and partnership; career spanning education and training; and health systems, policy and management. Rating of statements allowed the generation of go-zone maps for further interrogation of the relative importance, feasibility, and achievement of each patient-centred care requirement and cluster.

CONCLUSION

The study has empirically determined requirements for patient-centred care through the development of ROPCCS. The unique map emphasises collaborative responsibility of stakeholders to ensure that patient-centred care is comprehensively progressed. ROPCCS allows the complex requirements for patient-centred care to be understood, implemented, evaluated, measured, and shown to be occurring.

5-year follow-up of a randomised controlled trial of the effects of mindfulness practice on medical practitioners’ stress

This article was migrated. The article was not marked as recommended. BackgroundStress and psychological distress are common in doctors and have adverse effects for both doctors and patients.ObjectiveThis study aimed to investigate the long-term (5-year) effects of mindfulness practice on medical practitioners' stress.MethodsA 5-year follow-up study using quantitative and qualitative data analysis. Outcome measures of the original trial, Perceived Stress Scale (PSS) and Depression, Anxiety, Stress Scale (DASS), were repeated and a questionnaire/interview on doctors' health and well-being was undertaken.Results Most participants (88%) continue to use mindfulness or relaxation exercises. Mean outcome scores (and standard deviations) at 5 year follow up revealed; PSS 13.8 (5.2) (maximal score of 40), anxiety subscale of DASS 4.4 (4.9) (maximal score of 42 and stress subscale of DASS 10.9 (7.3) (maximal score of 42). The 5 year follow up group mean PSS and DASS outcomes scores were all lower than post intervention scores from the original RCT, however differences were not statistically significant. Participants expressed concerns with the overall state of doctors' health/wellbeing.ConclusionMindfulness for stress management is sustainable and may be beneficial for long term use in doctors.

Obstetric and Perinatal Morbidity in Northern Tasmanian Aboriginal Population: A Retrospective Cohort Study

INTRODUCTION

Aboriginal and Torres Strait Islander women are at increased risk of maternal morbidity and mortality as compared to non-Aboriginals. Similarly, aboriginal babies are at increased risk of low birth weight and infant mortality.

AIM

To investigate the independent association of aboriginality with Tasmanian maternal and neonatal morbidity.

MATERIALS AND METHODS

A retrospective analysis of all the births (gestation more than 20 weeks) from June 2013 to May 2014 was conducted at the Launceston General Hospital, Tasmania. The study compared 66 Aboriginal (4.2% of the total births) to 1477 non-aboriginal births for maternal and neonatal morbidity. Comparisons were made using logistic regression. The outcome measures were maternal and neonatal morbidity.

RESULTS

Significantly higher number of aboriginal women (49% vs 19%; OR 4.15 90%CI 2.52- 6.85) smoked and used illicit drugs (15% vs 2%; OR 9.24; 95%CI 4.28-19.96) than the non-aboriginal women (both p<0.001). Maternal morbidity was not significantly different between aboriginal compared to non-aboriginal women (OR 0.64; 95%CI 0.36-1.14; p=0.13; adjusted OR 1.00; 95%CI 0.52-1.93; p=0.99). Factors positively associated with maternal morbidity included: age (OR 1.28; 95%CI 1.13-1.46; p<0.01) and BMI (OR 1.50; 95%CI 1.33-1.70; p<0.01). The unadjusted OR of neonatal morbidity for aboriginality was 1.98 (95%CI 1.17-3.34; p=0.01) and adjusted was 1.45 (95%CI 0.77-2.72; p=0.25). Factors positively associated with neonatal morbidity included smoking (OR 2.24; 95%CI 1.59-3.14; p<0.01), illicit drug use 95%CI 1.49-(OR 3.26; 95%CI 1.49-7.13; p <0.01), hypertension (OR 2.49; 95%CI 1.61-3.84; p<0.01) and diabetes (OR 1.92; 95%CI 1.33-2.78; p<0.01).

CONCLUSION

The composite Aboriginal maternal morbidity does not differ, however the increased rates of smoking and illicit drug use are largely responsible for neonatal morbidity. Along with strengthening strategies to decrease medical comorbidities in aboriginals, we recommend intensifying smoking and illicit drug cessation programs.

General Practitioners' knowledge and use of genetic counselling in managing patients with genetic cardiac disease in non-specialised settings

There have been over 40 cardiac diseases with a genetic cause identified to date. The management of most genetic cardiac diseases (GCDs) now necessitates multidisciplinary care, including the provision of genetic counselling. This study investigated the knowledge and management of GCDs by General Practitioners (GPs). Questionnaires were mailed out to 685 doctors working in general practice in Tasmania, Australia, with 144 responses (21 %) received. Results showed that the majority (77.8 %) of the responding doctors are managing at least one patient with GCD in their practice. However, GPs identified having limited confidence in the appropriate management of these conditions and indicated that they are very dependent on guidance from a cardiologist, including whether to refer a patient to genetic counselling. To our knowledge, this is the first Australian study that looks at the care of patients with GCD in the primary care sector. The knowledge gained will help us provide more appropriate care for patients who do not have immediate access to specialised services, particularly those outside metropolitan areas, and provides evidence for what resources can be offered to doctors working in general practice to help provide quality care for these patients.

Enhancing international medical graduates' communication: the contribution of applied linguistics

CONTEXT

International medical graduates (IMGs) make up one-third of the Australian medical workforce. Those from non-English-language backgrounds can face cultural and communication barriers, yet linguistic support is variable and medical educators are often required to provide feedback on both medical and communication issues. However, some communication difficulties may be very specific to the experiences of IMGs as second language users.

OBJECTIVES

This interdisciplinary study combines perspectives from applied linguistics experts and clinical educators to address IMGs' difficulties from multiple dimensions and to enhance feedback quality.

METHODS

Five video-recorded patient encounters with five IMGs were collected at Launceston General Hospital. Three clinical educators gave quantitative and qualitative feedback using the Rating Instrument for Clinical Consulting Skills, and two applied linguistics experts analysed the data for language, pragmatic and communication difficulties. The comparison of the educators' language-related feedback with linguistic analyses of the same interactions facilitated the exploration of differences in the difficulties identified by the two expert groups.

RESULTS

Although the clinical educators were able to use their tacit intuitive understanding of communication issues to identify IMG difficulties, they less frequently addressed the underlying issues or suggested specific remedies in their feedback.

CONCLUSIONS

This pilot study illustrates the effectiveness of interdisciplinary collaboration in highlighting the specific discourse features contributing to IMG communication difficulties and thus assists educators in deconstructing their intuitive knowledge. The authors suggest that linguistic insights can therefore improve communications training by assisting educators to provide more targeted feedback.

Committing to patient-centred medical education

BACKGROUND

Regular encounters of patients and medical students in a managed and structured consultation format, to focus on partnership in health care and chronic illness management, can address the student learning and professional development requirements facing contemporary medical education.

CONTEXT

To engage and maintain such a strategy demands commitment and a belief in the importance of patient-centred medicine. The mechanism by which the Launceston Clinical School, University of Tasmania, has embraced this challenge over 8 years is the Patient Partner Program (P3).

INNOVATION

Acknowledged as a program that enhances student learning, P3 features learning objectives that integrate the capabilities of managing the consultative craft and foster the growth of practitioners skilled in patient engagement.

IMPLICATIONS

The possibility for the development of insights into patient experiences, doctor-patient relationships and broader health care perspectives arise from such interactions. Additionally, P3 is a beacon of university-community engagement for medical schools, and therefore provides a platform for future research into students' learning with community patients, and the impact on patients engaged in such educational program. This article outlines the approach, impact and challenges of our medical school's commitment to patient-centred education. Regular encounters of patients and medical students can address the student learning and professional development requirements.

Mobile Phones as a Potential Vehicle of Infection in a Hospital Setting

The objective of this article is to investigate the potential role of mobile phones as a reservoir for bacterial colonization and the risk factors for bacterial colonization in a hospital setting. We screened 226 staff members at a regional Australian hospital (146 doctors and 80 medical students) between January 2013 and March 2014. The main outcomes of interest were the types of microorganisms and the amount of contamination of the mobile phones. This study found a high level of bacterial contamination (n = 168/226, 74%) on the mobile phones of staff members in a tertiary hospital, with similar organisms isolated from the staff member's dominant hand and mobile phones. While most of the isolated organisms were normal skin flora, a small percentage were potentially pathogenic (n = 12/226, 5%). Being a junior medical staff was found to be a risk factor for heavy microbial growth (OR 4.00, 95% CI 1.54, 10.37). Only 31% (70/226) of our participants reported cleaning their phones routinely, and only 21% (47/226) reported using alcohol containing wipes on their phones. This study demonstrates that mobile phones are potentially vehicles for pathogenic bacteria in a hospital setting. Only a minority of our participants reported cleaning their phones routinely. Disinfection guidelines utilizing alcohol wipes should be developed and implemented.

Women's maternity care needs and related service models in rural areas: A comprehensive systematic review of qualitative evidence

BACKGROUND

Understanding the needs of rural women in maternity care and service models available to them is significant for the development of effective policies and the sustainability of rural communities. Nevertheless, no systematic review of studies addressing these needs has been conducted.

OBJECTIVES

To synthesise the best available evidence on the experiences of women's needs in maternity care and existing service models in rural areas.

METHODS

Literature search of ten electronic databases, digital theses, and reference lists of relevant studies applying inclusion/exclusion criteria was conducted. Selected papers were assessed using standardised critical appraisal instruments from JBI-QARI. Data extracted from these studies were synthesised using thematic synthesis.

FINDINGS

12 studies met the inclusion criteria. There were three main themes and several sub-themes identified. A comprehensive set of the maternity care expectations of rural women was reported in this review including safety (7), continuity of care (6) and quality of care (6), and informed choices needs (4). In addition, challenges in accessing maternity services also emerged from the literature such as access (6), risk of travelling (9) and associated cost of travel (9). Four models of maternity care examined in the literature were medically led care (5), GP-led care (4), midwifery-led care (7) and home birth (6).

CONCLUSION

The systematic review demonstrates the importance of including well-conducted qualitative studies in informing the development of evidence-based policies to address women's maternity care needs and inform service models. Synthesising the findings from qualitative studies offers important insight for informing effective public health policy.