Medical professionalism frameworks across non-Western cultures: A narrative overview.

BACKGROUND: Medical professionalism is context-specific, but most literature on professionalism stems from Western countries. This study is about benchmarking of different frameworks on professionalism and interpreting the commonalities and discrepancies of understanding professionalism across different cultures. We need to study the cultural underpinning of medical professionalism to graduate future "global" practitioners who are culturally sensitive enough to recognize differences (and also similarities) of expectations of patients in various contexts. AIM: This study aims at describing culture specific elements of three identified non-Western frameworks of professionalism, as well as their commonalities and differences. METHOD: A narrative overview was carried out of studies that address professionalism in non-Western cultures in the period 2002-2014. RESULTS: Out of 143 articles on medical professionalism, only four studies provided three structured professionalism frameworks in non-Western contexts. Medical professionalism attributes in non-Western cultures were influenced by cultural values. Out of the 24 identified attributes of professionalism, 3 attributes were shared by the three cultures. Twelve attributes were shared by at least two cultures, and the rest of the attributes were unique to each culture. CONCLUSIONS: The three frameworks provided culture-specific elements in a unique conceptual framework of medical professionalism according to the region they originated from. There is no single framework on professionalism that can be globally acknowledged. A culture-oriented concept of professionalism is necessary to understand what the profession is dedicated to and to incorporate the concept into the medical students' and physicians' professional identity formation.

Determinants of effective clinical learning: a student and teacher perspective in Saudi Arabia.

CONTEXT: Graduating clinically competent medical students is probably the principal objective of all medical curricula. Training for clinical competence is rather a complex process and to be effective requires involving all stakeholders, including students, in the processes of planning and implanting the curriculum. This study explores the perceptions of students of the College of Medicine at King Abdul-Aziz Bin Saud University for Health Sciences (KASU-HS), Riyadh, Saudi Arabia of the features of effective clinical rotations by inviting them to answer the question: "Which experiences or activities in your opinion have contributed to the development of your clinical competence? This college was established in 2004 and adopted a problem-based learning curriculum. METHODS: This question was posed to 24 medical students divided into three focus groups. A fourth focus group interview was conducted with five teachers. Transcriptions of the tape-recorded focus group interviews were qualitatively analyzed using a framework analysis approach. FINDINGS: Students identified five main themes of factors perceived to affect their clinical learning: (1) the provision of authentic clinical learning experiences, (2) good organization of the clinical sessions, (3) issues related to clinical cases, (4) good supervision and (5) students' own learning skills. These themes were further subdivided into 18 sub-themes. Teachers identified three principal themes: (1) organizational issues, (2) appropriate supervision and (3) providing authentic experiences. CONCLUSION: Consideration of these themes in the process of planning and development of medical curricula could contribute to medical students' effective clinical learning and skills competency.

Stress and coping strategies among Arab medical students: towards a research agenda.

BACKGROUND: Research conducted in the past ten years in the area of stress and coping among Arab medical students has identified some important issues, but other significant aspects have not yet been explored. OBJECTIVES: To provide a systematic review of studies reporting on stress, anxiety and coping among Arab medical students and to identify implications for future research. METHODS: PubMed was searched to identify peer-reviewed English-language studies published between January 1998 and October 2009 reporting on stress and coping among undergraduate Arab medical students. Search strategy used combinations of the terms: Arab medical student, stress, PBL, psychological distress, depression, anxiety and coping strategies. Demographic information on respondents, instruments used, prevalence data and statistically significant associations were abstracted. RESULTS: The search identified 8 articles that met the specified inclusion criteria. Within the limited range of Arab medical students studied, studies suggest these students have a high prevalence of perceived stress, depression and anxiety, with levels of perceived psychological stress as high as those reported in the international literature for medical students of other regions of the world. Limited data were available regarding coping strategies, the impact of stress on academic performance and attrition among Arab students. No data were available regarding the impact of problem-based learning on stress and coping. CONCLUSIONS: The existing literature confirms that stress, depression and anxiety are common among Arab medical students, as for students elsewhere. Little is known about the contribution of different curricula approaches to perceived stress and what coping strategies institutions and students apply to help alleviate stress. Large, prospective, multicentre, multi-method studies are needed to identify personal and curricula features that influence stress, depression, anxiety and coping strategies among Arab students.

Criteria for a good referral system for psychiatric patients: the view from Saudi Arabia.

The development and implementation of quality referral systems reflects sound national health planning. This review appraised the data on referral systems, in particular psychiatric referrals, with special reference to Saudi Arabia. A computer search was made of relevant literature in the past 2 decades. The rate and process of referring patients through referral letters varies globally across practice settings and is initiated by an array of factors linked with health consumers, health providers and delivery systems. Referral systems, including consultation-liaison services, are an essential component of any health care organization for offering a complete range of good quality, specialized health services.

Factors influencing patient choice of hospitals in Riyadh, Saudi Arabia.

This study examined factors considered important in choosing a hospital. The sample consisted of 303 respondents selected from five randomly selected primary health care centres. The percentages of males, highly educated, high-income level, elder and private sector employees was higher in those choosing private sector hospitals, while marital status did not relate to type of hospital. The principal component analysis identified six factors accounting for 64% of the total variance. The most important component was 'medical services' accounting for 28% of the total variance. Stepwise discriminant analysis revealed that the main factors associated with choosing a hospital were medical services, accessibility, age, sex and education. Little importance was given to income and occupation. Future recommendations outline the need for consumers' perceptions, attitudes, suggestions and concerns to be taken into consideration when marketing the services to be provided.

Physician-Nurse communication. Perceptions of Physicians in Riyadh.

OBJECTIVE: The need for communication between nurse and physician in clinical practice is undisputed. The objectives of this study were to describe doctors' perceptions of their communication with nurses, as related to the openness of the communication and the accuracy of the information communicated and to examine if specific sociodemographic characteristics concerning physicians were associated with perception of communication. METHODS: The sample consisted of 200 physicians selected randomly from 6 randomly selected hospitals representing both general and private. A modified Shortell's Intensive Care Unit physician-nurse communication subscale was used to measure the physician's perceptions of the degree to which openness and accuracy described their communication with nurses. Data was collected via a self-administered pilot questionnaire, which also included sociodemographic characteristics. RESULTS: The overall mean score for openness was 2.61 and 3.19 for accuracy out of a maximum score of 5. For openness the highest mean score was obtained for "listening to physician (4.31)" and the lowest mean score was obtained for "hospital environment (1.84)". For accuracy, the highest mean score was obtained for "use of medical language (4.37)" and the lowest mean score was for "feedback (1.84)". The results showed a significant difference for experience, age and gender for both types of hospitals. For specialization, title and nationality no significant difference was observed for both types of hospitals for openness and accuracy. Multivariate regression analysis showed that gender, age and experience were the predictor variables for openness and accuracy. With more experienced, older aged females, having the highest mean score. CONCLUSION: Communication between physician and nurses needs not remain only a researchable issue; its viability and vitality are crucial to the changing health care scene. Thus, the development of health delivery models that will enable effective multidisciplinary communication, cooperation and wiser use of limited resources in health care is essential.

Satisfaction and correlates of patients' satisfaction with physicians' services in primary health care centers.

OBJECTIVE: To estimate quantitatively consumers' satisfaction and correlates of satisfaction with physicians' services provided by Ministry of Health Primary Health Care Centers in attending consumers. METHODS: Consumers (n = 540) attending the selected Primary Health Care Centers in Riyadh were asked about their satisfaction with physician's services. Eight Primary Health Care Centers were randomly selected according to the geographical location, two from each geographical zone. Seventy-five subjects were selected systematically where every tenth Saudi aged 15 years and above who visited the selected Primary Health Care Centers during the study period was chosen. Data was collected via a self administered pilot tested, internally consistent patient satisfaction questionnaire which included socio-demographic characteristics as well as the overall and differential satisfaction with the different aspects of physicians' services in the selected Primary Health Care Centers rated in a scale of 1 5 points, the higher the score the higher the satisfaction. RESULTS: The results revealed that males constituted 60%, and 58% of all patients were married, more than 60% were employees and more than 70% have a monthly income of less than 6000 Saudi Riyals. Almost 95% have an open file in the Primary Health Care Center and 39% think that the distance to the Primary Health Care Center is far or very far. The summary satisfaction score was 3.77 points and the mean satisfaction with the services provided by physicians was 2.56 points out of a maximum of 5 points The highest satisfaction was for discussing psychological aspects of patients' problems (2.96 points) and the lowest was for attentive listening to patients' complaints (2.22 points). Physicians' communication skills were more satisfactory to patients than their professional skills and satisfying patients' wishes scored the lowest satisfaction- Unskilled laborers, literate patients and patients with higher income showed significantly higher mean satisfaction while students, illiterates, those aged less than 50 years and patients with income less than 6000 Riyals per months scored the lowest satisfaction. The longer the distance travelled the lower the satisfaction scores but having a file or not was not related to satisfaction. CONCLUSION: Some physicians' service items need corrective intervention and students and young patients appear to need more attention.

Psychiatric co-morbidity in primary care and hospital referrals, Saudi Arabia.

Psychiatric and physical morbidities among patients referred from primary health care (PHC) centres and general hospitals (GH) in Al-Qassim region were compared. Thus, 540 psychiatric referrals (GH = 138; PHC = 402) were selected randomly. Fifteen GH patients but no PHC patients were referred for admission. Psychiatrists made more diagnoses of dementia, affective and anxiety disorders, mixed anxiety-depression and somatoform disorders than clinicians and general practitioners (GPs). Clinicians made significantly more diagnoses of acute psychoses and somatoform disorders than GPs. Physical morbidity was noted in 38.4% and 17.2% of GH and PHC referrals respectively.

A taxonomy of community-based medical education.

The authors propose a classification of community-based education (CBE) as it is implemented all over the world. To create this taxonomy, they used reports in the literature of 31 active programs in many locations. A CBE program is an instructional program carried out in a community context, outside the academic hospital. The authors distinguish between programs that are developed primarily to provide services to an underserved community; programs that have a research focus; and programs that have as their primary goal the (clinical) training of students. These three major types can be subdivided in six minor types, among them community development programs, health intervention programs, and simple community-exposure programs. The ultimate goal of creating the taxonomy is to contribute to the development of a theory of CBE and provide a more systematic way to study CBE. In addition, the proposed taxonomy clearly demonstrates the various ways in which medical schools, their staffs, and their students can become involved with the communities served. CBE is not a unitary concept but a set of attempts to contribute to the quality of life in a particular community and, at the same time, create conditions for students to acquire hands-on understanding of the nature of the problems to be faced in future professional practice, and to develop relevant skills. The taxonomy also enables those involved in the development of CBE programs in their medical schools to see alternative approaches, which will help them choose the approaches that fit their particular educational goals. Last, it demonstrates the intricacies involved in the implementation of CBE, in particular the complexity of building a learning environment that is productive for students and, at the same time, responsive to community needs.

Testing a causal model of community-based education in the Sudan.

PURPOSE: To develop and test a model of community-based education. METHOD: In 1995, after developing a hypothesized causal model for community-based education, the authors collected data for 106 students at the University of Gezira, the Sudan, who had participated over three summers in an interdisciplinary field training research and rural development course. The students rated each other on leadership, interaction with the community, subject-matter contributions, and effort. Teaching staff assessed the readiness of the community to collaborate. The students' achievement was measured by short essays measuring knowledge, supervisors' assessments of the students' performances in the community, the community's observations of the students' activities, the community's satisfaction, and a group-produced report evaluated by faculty. The effect of the students' activities on the community was measured by comparing baseline and post-intervention community health data. The students also indicated their levels of interest in the community's problems. The authors analyzed the resulting covariances using structural-equations modeling. RESULTS: After minor adaptations, the model fitted the data reasonably well. The path coefficients were quite high, particularly among the peer ratings. Leadership had a potent effect on the outcome measures, as did, to a lesser extent, the readiness of the community to collaborate with the students. CONCLUSION: This study was the first reported attempt to test a model of community-based education. Although the fit of the data to the model in the study was reasonable, further study is needed to unearth additional important elements of community-based education. This article also discusses methodologic shortcomings of the present study, such as a possible "halo effect" in the peer ratings and the retrospective nature of many of the measurements.

Student assessment in community settings: a comprehensive approach.

Student assessment in community settings presents problems for medical teachers, e.g., difficulties in assessing the contribution of individual members to group work, and lack of test standardization due to varying field conditions. The Faculty of Medicine, University of Gezira, Sudan is a community-oriented, community-based medical school which has adopted a comprehensive approach to student assessment in community settings using various methods, including peer assessment, a supervisory checklist, community feedback, reports from students, short essay questions (SEQs) and multiple choice questions (MCQs). Each method focuses on a specific aspect of the objectives of the community-based programme and is weighted in the final grade according to the extent to which objectives were covered. This assessment programme contrasts with the conventional teacher-centred approach, and is continuously monitored and improved using a variety of sources of information. A total of 105 students participated in a study designed to measure the reliability and validity of this approach. The reliability of the methods was tested by computing the alpha coefficient and was found to range between 0.77 and 0.92. This was considered acceptable. The validity of the instruments was examined using confirmatory factor analysis, and their content validity was reviewed. The results show that the comprehensive approach used is fairly valid. It is suggested that the University's approach is successful in solving some of the problems of student assessment in community settings.

An outbreak of dracunculiasis in central Sudan.

This paper describes an outbreak of dracunculiasis in Mazmum, a town in central Sudan. The study included collection of clinical and epidemiological data from 319 patients treated in hospital, a review of the hospital records, a house survey covering a sample of 757 subjects, a school survey covering 1390 schoolchildren, and examination of water sources. The overall incidence of the disease was 23.4%, with most cases appearing in the agricultural season (July-October). Incidence was highest in young females but most severe disability occurred in male patients aged > or = 20 years, of whom more than 60% were unable to work for more than 4 weeks. The disease is transmitted in shallow natural pools, artificial ponds and trenches in rocky hills that hold rain water. All these sources were found to be infested with Cyclops. The outbreak is attributed to deterioration in the structure and management of the water sources, together with a massive population influx from other endemic areas. These observations underscore the importance of co-ordinating efforts to eradicate the disease from African countries.