'Going rural': driving change through a rural medical education innovation.

INTRODUCTION: Medical education across the globe is in a state of flux influenced by a number of drivers for change. In response, institutions are seeking to re-align their curricula to address the prevailing imperatives. Against this backdrop, the training of practitioners for practice in rural communities was identified as an educational priority, and led to the establishment of a rural clinical school (RCS) within a Faculty of Medicine and Health Sciences in South Africa in 2011. This article describes the students' experiences in the first year that this innovative educational model was implemented and explores the extent to which it influenced their thinking and practice. METHODS: A qualitative, formative evaluation study of the first year of implementation was undertaken. Data was generated from in-depth interviews. This article focuses on individual interviews conducted with the eight students at the RCS, which explored their experiences during a year-long clerkship. Transcripts of interviews were thematically analysed. RESULTS: Four themes emerged from the analysis: a learning experience that differed from what was experienced at the tertiary training hospital, an enabling clinical environment in the district and regional hospital, the positive role played by the specialists, and the influence of the community immersion. Underlying all of the responses was the building of relationships over time both with supervisors and with patients. Evident from the responses was that students' confidence in their clinical skills and decision-making abilities was heightened while their approaches to their own learning were enhanced. CONCLUSIONS: To respond to the call for educational reform and a heightened awareness of social realities, innovative approaches to the training of medical students, such as those adopted at the RCS, are indicated. It is argued that the learning facilitated by these rural medical education models has the potential to offer learning experiences that can lead to transformation through a change in practice and attitude among the students, and ultimately also enable curricular renewal at the institutional core.

Developing an educational research framework for evaluating rural training of health professionals: a case for innovation.

BACKGROUND: World-wide, rural clinical training of undergraduate medical students is looking to transform learning experiences, calling for the adoption of innovative approaches that create spaces for curriculum renewal and new ways of thinking. In order for these teaching models to gain acceptance and credibility among the relevant academic communities, it is critical that they be studied and evaluated. AIM: This article describes an innovative rural education intervention and a concomitant, intentional process that was adopted to establish a research framework within which the intervention will be evaluated. METHODS: Key role-players participated in a one-day workshop aimed at developing the framework. A collaborative, structured process that moved through three phases of deliberation and reflection was followed. RESULTS: The documentation and raw data generated during the workshop was used to generate the framework that will serve as a blueprint for ensuring the study and evaluation of the educational innovation. CONCLUSION: Establishing an educational research framework, by adopting a consultative and collaborative process, provides a vehicle for encouraging a culture of critical accountability that seeks to discern evidence of good practice in the training of health care workers in a rural context.

Perceived educational value and enjoyment of a rural clinical rotation for medical students.

INTRODUCTION: It is well-recognised that medical students whose training exposure is largely limited to tertiary-level training hospitals may be inappropriately equipped to deal with the most relevant health issues affecting rural communities. This article evaluated the perceived educational value of a 2 week clinical rotation undertaken by senior undergraduate medical students at rural district hospitals and health care centers in the Western Cape Province, South Africa. METHODS: Students completed a daily log diary to provide an overview of time spent on specific academic activities, ranking the educational and enjoyment value of each activity. At the end of the 2 week rotation students completed an open-ended questionnaire capturing the main positive and negative aspects of their experience, followed by focus group discussions with a randomly selected subgroup. In addition, a formal feedback seminar was arranged with the academic supervisors at each of the training sites to triangulate the information received and to document their perspective. RESULTS: Thirty-seven students consented to study participation and 25 (68%) adequately completed the log diaries and questionnaires, rating the following activities as most educational: 'assisting in theatre', 'teaching by doctor', 'seeing patients in clinic/health centre/OPD' and 'mobile clinic excursions'. The rural experience allowed practical application of their theoretical knowledge, which improved their levels of confidence and enjoyment. The most enjoyed activities were: 'mobile clinic excursions', 'performing medical procedures' and 'teaching by doctor'. The students were critical of some aspects: (i) the rural rotation was not structured efficiently; (ii) compulsory written reports and additional projects prevented them from maximizing the rural experience; and (iii) a time period of 2 weeks was felt to be too short for optimum benefit from the rotation. CONCLUSION: The feedback obtained from this log diary study demonstrates that well-functioning rural health care centers provide excellent opportunities for students to develop the most relevant practical skills required of generalist doctors working in resource-limited settings. In addition to a more efficiently structured rural program, students requested an increase in the length of the rotation and a reduction in the written academic workload.

'Going the extra mile': Supervisors' perspectives on what makes a 'good' intern.

BACKGROUND: Much has been published on whether newly graduated doctors are ready for practice, seeking to understand how to better prepare graduates for the workplace. Most studies focus on undergraduate education as preparation for internship by investigating knowledge and skills in relation to clinical proficiencies. The conversion from medical student to internship, however, is influenced not only by medical competencies, but also by personal characteristics and organisational skills. Most research focuses largely on the interns' own perceptions of their preparation. Supervisors who work closely with interns could therefore present alternative perspectives. OBJECTIVES: To explore the views of medical intern supervisors on the internship training context, as well as their perspectives on attributes that would help an intern to function optimally in the public health sector in South Africa (SA). This article intends to extend our current understanding of what contributes to a successful internship by including the views of internship supervisors. METHODS: Twenty-seven semi-structured interviews were held with medical intern supervisors in 7 of the 9 provinces of SA. The data were thematically analysed and reported using an existing framework, the Work Readiness Scale. RESULTS: The intern supervisors indicated that interns were challenged by the transition from student to doctor, having to adapt to a new environment, work long hours and deal with a large workload. Clinical competencies, as well as attributes related to organisational acumen, social intelligence and personal characteristics, were identified as being important to prepare interns for the workplace. Diligence, reliability, self-discipline and a willingness to work ('go the extra mile') emerged as key for a 'good' intern. The importance of organisational skills such as triage, prioritisation and participation was foregrounded, as were social skills such as teamwork and adaptability. CONCLUSIONS: This article contributes to our understanding of what makes a successful medical internship by exploring the previously uncanvassed views of intern supervisors who are working at the coalface in the public health sector. It is envisaged that this work will stimulate debate among the medical fraternity on how best to prepare interns for the realities of the workplace. Educational institutions, health services and interns themselves need to take ownership of how to instil, develop and support these important attributes.

South African medical schools: Current state of selection criteria and medical students' demographic profile.

BACKGROUND: Selection of medical students at South African (SA) medical schools must promote equitable and fair access to students from all population groups, while ensuring optimal student throughput and success, and training future healthcare practitioners who will fulfil the needs of the local society. In keeping with international practices, a variety of academic and non-academic measures are used to select applicants for medical training programmes in SA medical schools. OBJECTIVES: To provide an overview of the selection procedures used by all eight medical schools in SA, and the student demographics (race and gender) at these medical schools, and to determine to what extent collective practices are achieving the goals of student diversity and inclusivity. METHODS: A retrospective, quantitative, descriptive study design was used. All eight medical schools in SA provided information regarding selection criteria, selection procedures, and student demographics (race and gender). Descriptive analysis of data was done by calculating frequencies and percentages of the variables measured. RESULTS: Medical schools in SA make use of academic and non-academic criteria in their selection processes. The latter include indices of socioeconomic disadvantage. Most undergraduate medical students in SA are black (38.7%), followed by white (33.0%), coloured (13.4%) and Indian/Asian (13.6%). The majority of students are female (62.2%). The number of black students is still proportionately lower than in the general population, while other groups are overrepresented. CONCLUSION: Selection policies for undergraduate medical programmes aimed at redress should be continued and further refined, along with the provision of support to ensure student success.

Self-injection ictal SPECT during partial seizures.

The authors compared ictal SPECT injection performed by medical personnel with self-injection ictal SPECT in six patients with refractory temporal lobe epilepsy. Self-injection was safe and started faster. Self-injection subtraction ictal SPECT coregistered to MRI (SISCOM) was localizing in three patients who had a complex partial seizure, but only one of three patients who had a simple partial seizure, which may limit its usefulness in clinical practice. The localizing information of self-injection was better in three patients, and obviated the need for depth-EEG studies in one patient.

Functional brain imaging and pharmacotherapy in social phobia: single photon emission computed tomography before and after treatment with the selective serotonin reuptake inhibitor citalopram.

1. Despite increased understanding of the prevalence and pharmacotherapy of social phobia (or social anxiety disorder), the neurobiology of the disorder is little understood. 2. Little data exists on the effect of pharmacotherapeutic intervention on regional cerebral blood flow (rCBF) in this disorder. Patients (n=15) who met DSM-IV diagnostic criteria for social phobia were subjected to single photon emission computed tomography (SPECT) with technetium-99m hexamethylpropylene amine oxime (Tc-99m HMPAO) before and after an eight-week trial of pharmacotherapy with the selective serotonin reuptake inhibitor (SSRI) citalopram. 3. Pharmacotherapy led to significantly reduced activity in the anterior and lateral part of the left temporal cortex; the anterior, lateral and posterior part of the left mid frontal cortex; and the left cingulum. 4. Despite the small sample size, medication non-responders (n=6) had higher activity at baseline in the anterior and lateral part of the left temporal cortex and the lateral part of the left mid frontal regions compared with responders (n=9). These data from this exploratory study are consistent with work suggesting that the anxiety disorders share certain mediating neurocircuitry, although activity in other brain regions may differ. 5. Further research is necessary to determine the neurobiological underpinnings of social phobia.

Single photon emission computed tomography of the brain with Tc-99m HMPAO during sumatriptan challenge in obsessive-compulsive disorder: investigating the functional role of the serotonin auto-receptor.

1. Symptoms of obsessive-compulsive disorder (OCD) may be acutely exacerbated by administration of certain serotonin agonists Exacerbation of OCD symptoms by sumatriptan, a 5HT1D agonist (Zohar, 1993), is consistent with pre-clinical data suggesting that the serotonin auto-receptor plays an important role in this disorder (El Mansari et al, 1995). 2. In order to investigate the functional role of the serotonin auto-receptor in OCD, the authors undertook single photon emission computed tomography in OCD patients after administration of sumatriptan and placebo. The authors hypothesized that, as in the case of m-chlorophenylpiperazine (mCPP) challenge (Hollander et al, 1995), exacerbation of OCD symptoms would be accompanied by increased cortical metabolism and thus blood flow, and more specifically by increased activity in the orbitofrontal-striatal circuit. They also expected, that as in the case of mCPP challenge (Hollander et al, 1993), exacerbation of OCD symptoms would be associated with a relatively poor response to subsequent treatment with serotonin specific reuptake inhibitors. 3. Sumatriptan (100 mg orally) and placebo were administered on separate days to 14 patients who met DSM-IV diagnostic criteria for OCD, using a randomized double-blind design. After 90 minutes, patients were injected with Tc-99m HMPAO and underwent single photon emission computed tomography (SPECT) of the brain. Activity in regions of interest was calculated, and compared using repeated measures analysis of variance. Patients were subsequently treated with a serotonin specific reuptake inhibitor (SSRI). 4. Behavioral response to sumatriptan was heterogenous, with 4 patients showing acute exacerbation, and 4 patients demonstrating a decrease in symptoms. On sumatriptan challenge, there was a significant association between symptom exacerbation and decreased activity in frontal areas. There was an association between decreased activity in an inferior frontal area with worse response to treatment, and also patients with symptom exacerbation after sumatriptan had poorer response to SSRI treatment. 5. Heterogeneity of behavioral response to sumatriptan in OCD is consistent with previous studies demonstrating conflicting and heterogenous behavioral responses to serotonergic challenges (Hollander et al, 1992), and with underlying heterogeneity in the neurobiology of this disorder. 6. It may be hypothesized that increased frontal activity in some patients with OCD is itself a compensatory mechanism. In patients with such compensatory hyperactivity, administration of a serotonin auto-receptor agonist results in decreased frontal activity and exacerbation of OCD symptoms. These patients may also be less likely to respond to treatment with a SSRI. 7. Further work combining pharmacological challenge paradigms and functional imaging techniques in OCD may be helpful in elucidating the neurobiology of this complex disorder.

Assessing adequacy of collateral circulation during balloon test occlusion of the internal carotid artery with 99mTc-HMPAO SPECT.

A balloon test occlusion of the internal carotid artery was performed in 11 patients with internal carotid artery aneurysms. Tolerance by patients was assessed by a combination of clinical examination; angiography; electroencephalography; 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) single-photon emission computed tomography (SPECT) with relative quantification; and, in four patients, 99mTc-HMPAO SPECT with absolute quantification of cerebral blood flow. During test occlusion, angiography showed a patent circle of Willis in all patients. No patient developed new clinical findings or electroencephalographic changes. The SPECT studies of five patients in whom 99mTc-HMPAO was injected during test occlusion demonstrated changes from their baseline SPECT studies. The internal carotid artery was permanently occluded in two of these patients, neither of whom became symptomatic because of the occlusion. Three patients who demonstrated no changes between baseline and test occlusion SPECT studies underwent permanent occlusion of the internal carotid artery without incident, and postoperative SPECT images were unchanged from baseline. Our preliminary results suggest that patients who have no changes between baseline and test occlusion 99mTc-HMPAO SPECT studies should have adequate collateral circulation to sustain cerebral blood flow after occlusion of the internal carotid artery if no thromboembolic episodes occur. In contrast, a patient's tolerance of permanent occlusion cannot be consistently and reliably predicted if there are changes between baseline and test occlusion SPECT studies. In these patients, absolute quantitation of cerebral blood flow is important. Greater numbers of patients are required to confirm these initial results.

Neuropsychiatry of hypersexuality.

Relatively few studies of the psychobiology of hypersexuality have been undertaken. Nevertheless, the literature does suggest the possibility of a neurobiology of hypersexuality. Three cases of hypersexual behavior are presented in the context of neuropsychiatric disorders, and the literature on this phenomenon is briefly reviewed. These case studies and the literature provide evidence that different brain systems may play a role in this disorder. Frontal lesions may be accompanied by disinhibition, including impulsive hypersexual response to external cues, while striatal lesions may be accompanied by repetitive triggering of internally generated response patterns. Temporal-limbic lesions may be accompanied by disturbances in sexual appetite itself, including change in the direction of sexual drive. These case studies demonstrate that a neurobiology of hypersexuality may prove of some heuristic value in the clinic. However, further research is required to consolidate the literature in this area.

Brain uptake of iodine-131 metaiodobenzylguanidine following therapy of malignant pheochromocytoma.

Intracranial metaiodobenzylguanidine (MIBG) uptake is occasionally and only faintly visualized on diagnostic studies. Recently, intense normal cerebellar uptake was described on posttherapy MIBG images. Experience at the University of Michigan with posttherapy MIBG scintigraphy of pheochromocytoma was reviewed. The patterns and correlates of intracranial uptake after therapeutic 1-131 MIBG in 25 patients (61 patient treatment encounters) were evaluated by review of records and blinded consensus interpretation of diagnostic and posttherapeutic MIBG scans. Thirty-nine (64%) patient treatment encounters demonstrated at least faint (grade 1) MIBG uptake in one or more brain sites; the most common site was the cerebellum. There was a statistically significant relation between intracranial uptake and 1) size of therapeutic dose and 2) patient age, but no relation between intracranial uptake and gender, body mass index, plasma epinephrine level, plasma norepinephrine level, urine metanephrine level, or the therapy-to-imaging interval. Although the influence of age on the pattern and intensity of intracranial uptake is unexplained, the relation to therapy dose may be explained by the possible generation of MIBG metabolites that can cross the blood-brain barrier (high activity administered and the delay until imaging). Further studies are needed to define mechanisms of intracranial uptake and relation to responses and toxicity after MIBG therapy of neuroendocrine tumors.

Effectively addressing the health needs of South Africa's population: the role of health professions education in the 21st century.

The causes of the poor health status of the South African population are probably multifactorial, but to be socially accountable we must ensure that the education and training of health professionals continue to be aligned with the population's health needs. The authors of a seminal report published in the Lancet in 2010 provide guidelines for the future training of health professionals. Since November 2010, this report, together with other guiding publications, informed a series of strategic initiatives undertaken by the Undergraduate Education and Training subcommittee of the Medical and Dental Professions Board of the Health Professions Council of South Africa (HPCSA). These initiatives seek to ensure alignment of the training of health professionals in South Africa (SA) with the health needs of the population and with international educational norms and standards. These initiatives are described and the role of the HPCSA in guiding the education and training of SA's health professionals is explored.

[The value of pinhole collimator imaging in the scintigraphic analysis of vertebral diseases]. / Die waarde van speldgatkollimator-opnames in die flikkergrafiese diagnose van werwelpatologie.

Recent findings suggested a possible role for pinhole collimator scintigraphy to differentiate between metastases, infection and fractures of the vertebrae. The aim of this study was to verify these findings and to ascertain whether we could identify any other specific scintigraphic patterns. The study group consisted of 58 patients. A metastatic pattern was obtained in 18 patients, while 16 showed the compression fracture pattern, 3 the tuberculosis pattern and 1 the pyogenic infection pattern. The study was considered normal in 4 patients and showed a nonspecific pattern in 4. Sensitivity was 85% for the metastatic pattern and 83% for the compression fracture pattern. Specificity was 94% for both patterns. Unique new patterns were identified in Paget's disease and in degenerative disease of the vertebrae (12 patients). Pinhole scintigraphy of the vertebrae is a valuable aid for detecting specific diseases of the vertebrae. Our findings suggest a valuable new role for skeletal scintigraphy, improving the specificity and obviating, in most cases of vertebral disease, the need for additional investigations.

Pica and the obsessive-compulsive spectrum disorders.

BACKGROUND: The concept of a spectrum of obsessive-compulsive related disorders may have clinical and research heuristic value in the approach to disorders similar to obsessive-compulsive disorder (OCD) in respect of phenomenology and psychobiology. Like other repetitive and ritualistic behaviours, pica may be postulated to fall at times on this spectrum. METHODS: Five cases of pica seen at our clinics are presented here in order to test this hypothesis. Phenomenology, neurobiology (where available) and pharmacotherapy data are provided in order to consider a possible relationship with OCD and OCD spectrum disorders. RESULTS: In 2 of the cases, pica appeared to be a compulsion and patients had additional symptoms which met diagnostic criteria for OCD. In 2 of the cases, the clinical picture and neurobiological data were reminiscent of an impulse control disorder. Four of the 5 patients responded to treatment with a serotonin re-uptake inhibitor (SRI). CONCLUSION: These results are consistent with a hypothesis that at least some cases of pica may usefully be conceptualised as lying within a compulsive-impulsive spectrum of symptoms and disorders.

[The effect of heparin induced increase of free plasma thyroxine on cardiac rhythm after myocardial infarction]. / Die effek van heparien-geïnduseerde styging in vrye plasmatiroksien op die hartritme na miokardiale infarksie.

It is well known that an acute myocardial infarction is accompanied by a rise in levels of plasma free fatty acids (FFA), which may lead to a subsequent increase in cardiac arrhythmias. Administration of heparin to patients after an acute myocardial infarction gives rise to an increase both in plasma FFA levels and plasma free thyroxine levels. If administered without a fatty meal the rise in FFA is not accompanied by an increase in arrhythmias. The effect of the heparin-induced rise in plasma free thyroxine on cardiac rhythm has never been investigated. The aim of the present study was to investigate a possible arrhythmic effect of a heparin induced increase in plasma free thyroxine in a group of patients with acute myocardial infarction. We were able to confirm a significant heparin-induced rise in plasma free thyroxine levels, as measured by the effective thyroxine ratio. Although a slightly significant increase in ventricular premature beats could be demonstrated after heparin administration when using the Wilcoxon rank sum test for statistical analysis (but not when the paired t-test was utilized), no significant correlation with free thyroxine levels could be found. Heparin administration to patients suffering from myocardial infarction seems to be safe in terms of a possible arrhythmic effect.

99mTc-MIBI stress-rest myocardial perfusion scintigraphy in patients with complete left bundle branch block.

BACKGROUND: Patients with complete left bundle branch block (LBBB) often show a false-positive ischaemic pattern in the interventricular septum on thallium-201 (201TI) stress-rest myocardial perfusion scintigraphy. Equivocal results have been reported with technetium-99m labelled hexakis-methoxyisobutyl isonitrile (99mTc-MIBI) in such patients. The aim of this retrospective study was to determine the effect of LBBB on the septal uptake of 99mTc-MIBI during stress-rest single photon emission computed tomography (SPECT) scintigraphy. METHODS: We studied 75 consecutive patients with LBBB, referred for 99mTc-MIBI stress-rest SPECT. Studies were evaluated by visual analysis using a semi-quantitative grading technique. In all patients with abnormal septal segments, the presence or absence of ischaemic heart disease was confirmed either clinically or by means of angiographical examination. RESULTS: Forty-three patients (57.3%) had completely normal studies. Only 15 (20%) had septal abnormalities (11 with reversible and 4 with fixed defects), while 17 patients (22.7% had abnormal segments in areas other than the interventricular septum. Except for 1 patient lost to follow-up, ischaemic heart disease was confirmed in all the patients with septal changes. CONCLUSION: We conclude that 99mTc-MIBI is more specific than 201TI for identifying ischaemic heart disease in the presence of LBBB.

Absence of pulmonary aspiration of sinus contents in patients with asthma and sinusitis.

The frequent association of asthma and paranasal sinusitis has been ascribed to a nasobronchial reflex, aspiration of sinus secretions, or enhanced beta-adrenergic blockade. We investigated possible pulmonary aspiration in a pilot study (eight patients) and follow-up study (13 patients) by means of a radionuclide technique. In the pilot study, the aim was to demonstrate aspiration as well as visibility of the radionuclide in the thorax during a period of 24 hours. The radionuclide was initially placed bronchoscopically in the bronchial tree in four patients and was still clearly visible in the same position after 24 hours in three patients. Aspiration from the nasopharynx was unequivocally demonstrated in two of four patients with depressed consciousness. The follow-up study population consisted of four patients with maxillary sinusitis only and nine patients with sinusitis and asthma. The radionuclide was placed in a maxillary sinus during therapeutic puncture. In the patients with only sinusitis as well as patients with asthma and sinusitis the radionuclide could be demonstrated in the maxillary sinus, nasopharynx, esophagus, and lower gastrointestinal tract during a 24-hour period. However, no pulmonary aspiration of radionuclide could be demonstrated in any patient. We conclude that seeding of the lower airways by mucopurulent secretions is unlikely to account for coexistent pulmonary disease. The association is probably related to generalized mucosal disease affecting both upper and lower airways.

Is olfactory reference syndrome an obsessive-compulsive spectrum disorder?: two cases and a discussion.

A number of disorders characterized by intrusive repetitive symptoms and varying degrees of insight may overlap phenomenologically and neurobiologically with obsessive-compulsive disorder (OCD). There is a question as to whether olfactory reference syndrome, a disorder characterized by persistent preoccupations about body odor accompanied by shame and embarrassment, is also an OCD spectrum disorder. Two cases of olfactory reference syndrome, with accompanying phenomenological and neurobiological data, are presented in order to discuss the possible overlap with OCD. A number of phenomenological and neurobiological features in these patients were at least partially reminiscent of OCD. In particular, despite having poor insight, both patients demonstrated significant improvement upon treatment with a serotonin reuptake inhibitor.

Are musical obsessions a temporal lobe phenomenon?

Obsessive musical tunes have been described in some cases of obsessive-compulsive disorder (OCD). The authors present 2 cases of patients with musical obsessions, including findings from functional brain imaging. Both patients, 1 with idiopathic OCD and 1 with symptoms secondary to head trauma, demonstrated decreased blood flow in temporal lobes. This finding is consistent with previous literature on musical and auditory hallucinations.