A value analysis of longitudinal integrated clerkships: consideration of costs and benefits.

Longitudinal Integrated Clerkships (LICs) prioritise longitudinal relationships with faculty, patients, and place. Research shows that LICs benefit students and faculty, but most medical schools have limited LIC programmes. This is likely due to perceptions that LICs are more costly and complex than traditional block rotations (TBRs). The perceived cost versus evidence-based value related to clerkship education has not been examined in detail. Until recently, no 'All-LIC' medical school exemplars existed in the US, limiting the value of this model as well as the ability to examine relative cost and complexity. In this paper, we draw on our experience launching three 'All-LIC' medical schools in the United States - schools in which the entire clerkship class participates in a comprehensive clerkship-year LIC. We propose that the known benefits of LICs coupled with cost-mitigation strategies related to running an 'All LIC' model for core clinical clerkships, rather than block and LIC models simultaneously, results in a higher value for medical schools.

Interprofessional Education to Address Substance Use among Adults with Persistent Pain: A Pre-Post Program Evaluation.

BACKGROUND: Substance use disorders (SUDs) are highly prevalent among adults with persistent pain. Yet, standard competencies for integrating pain and SUD content are lacking across health science student curricula. Additionally, pharmacotherapies to treat SUDs are underutilized. AIM: To address these gaps, a team of health science faculty created an interprofessional simulation activity using a standardized patient and evaluated learner outcomes related to assessment and treatment of comorbid persistent pain and substance use. METHODS: A total of 304 health science students representing nursing, medicine, pharmacy, and social work programs attended virtual learning sessions. Interprofessional student teams developed a team-based care plan for an adult with musculoskeletal pain who takes prescribed opioids while using alcohol. Pre- and post-activity surveys assessing knowledge and confidence were matched for 198 students. Descriptive statistics summarized survey data with inferential analysis of paired data. RESULTS: The largest significant improvements between pre- and post-activity knowledge were observed in items specific to pharmacotherapy options for alcohol and opioid use disorders. Similar gains were noted in students' confidence regarding pharmacotherapies. No significant differences were noted on pre-post-activity knowledge scores between the three main profession groups (medicine, nursing, and pharmacy). CONCLUSIONS: Students attending this interprofessional simulation demonstrated improved knowledge and confidence, particularly in pharmacotherapies for alcohol and opioid use disorders. Replication of such programs can be used to provide consistent content across health science disciplines to heighten awareness and receptivity to medications available to treat SUDs in people treated for persistent pain. The curriculum is freely available from the corresponding author.

Rural origin plus a rural clinical school placement is a significant predictor of medical students' intentions to practice rurally: a multi-university study.

INTRODUCTION: Health workforce shortages are a major problem in rural areas. Australian medical schools have implemented a number of rural education and training interventions aimed at increasing medical graduates' willingness to work in rural areas. These initiatives include recruiting students from rural backgrounds, delivering training in rural areas, and providing all students with some rural exposure during their medical training. However there is little evidence regarding the impact of rural exposure versus rural origin on workforce outcomes. The aim of this study is to identify and assess factors affecting preference for future rural practice among medical students participating in the Australian Rural Clinical Schools (RCS) Program. METHODS: Questionnaires were distributed to 166 medical students who had completed their RCS term in 2006; 125 (75%) responded. Medical students were asked about their preferred location and specialty for future practice, their beliefs about rural work and life, and the impact of the RCS experience on their future rural training and practice preferences. RESULTS: Almost half the students (47%; n=58) self-reported a 'rural background'. Significantly, students from rural backgrounds were 10 times more likely to prefer to work in rural areas when compared with other students (p<0.001). For those preferring general practice, 80% (n=24) wished to do so rurally. Eighty-five per cent (n=105) of students agreed that their RCS experience increased their interest in rural training and practice with 62% (n=75) of students indicating a preference for rural internship/basic training after their RCS experience. A substantial percentage (86%; n=108) agreed they would consider rural practice after their RCS experience. CONCLUSIONS: This baseline study provides significant evidence to support rural medical recruitment and retention through education and training, with important insights into the factors affecting preference for future rural practice. By far the most significant predictor of rural practice intention is recruitment of students with a rural background who also undertake an RCS placement. This research also demonstrates significant demand for post-graduate rural training places, including specialty places, as RCS graduates become junior doctors and vocational trainees.

A multi-university evaluation of the rural clinical school experience of Australian medical students.

INTRODUCTION: Medical students have been attending rural clinical schools (RCSs) since 2001. Although there have been generally positive single institution reports, there has been no multi-institution study using a common survey instrument. The experiences of medical students who attended a number of RCSs during 2006 were evaluated using a rural-specific questionnaire. METHODS: Questionnaires were distributed to 166 medical students who had completed one year at the RCS of six participating universities across Australia, including the Universities of New South Wales, Melbourne, Tasmania, Adelaide, and Sydney, and the Australian National University, of whom 125 responded (75.3%). Students were asked to rate their level of agreement on 29 items concerning their overall RCS experience, skills development and clinical supervision experience. RESULTS: The majority of respondents (n = 107, 86%) stated they would go to the RCS again if they had their time over and almost two-thirds (n = 77, 64%) stated they would spend more time at the RCS if they could. All items evaluating the educational experience recorded greater than 80% agreement (indicating very positive perceptions of the RCS experience). For the items concerning skills development, the highest level of agreement related to developing procedural skills (n = 121, 97%). For items relating to clinical supervision the agreement rate exceeded 80%. The majority of students found supervisors approachable (n = 121, 97%), enthusiastic (n = 120, 96%) and respectful (n = 119, 95%). CONCLUSIONS: Students' experiences in the RCSs are unequivocally positive. Most importantly, the RCS environment was conducive to learning and the development of clinical skills, the students were able to see an adequate number of patients and were well-prepared for examinations, and their supervisors were very good and acted as positive role models. This augers well for the success of the RCS program and for its role in attracting future doctors to work in rural environments.

A multi-university study of which factors medical students consider when deciding to attend a rural clinical school in Australia.

INTRODUCTION: As in many developed nations, there is a shortage in the rural medical workforce in Australia. Research indicates that a strong relationship exists between rural educational exposure and an increased interest in pursuing a rural career or selecting a rural internship. Accordingly, in 2000 the Australian Commonwealth Government established the Rural Clinical Schools (RCS) program. Under this program, 25% of parent medical schools' Commonwealth Supported Place (CSP) medical students must spend at least 1 year of their clinical medical education in a rural setting. Research indicates that positive experiences are of vital importance in determining future rural practice. Arguably, if students are conscripted to a RCS, they may view their overall experience negatively. Thus, the development and sustainability of an adequate future rural medical workforce depends on medical schools understanding and fostering the factors that encourage voluntary student recruitment to the RCSs. The aim of the present study was to determine which factors Australian medical students consider in their decision to attend RCSs. METHODS: This study employed survey research. The questionnaire, which used a 6 point Likert scale, addressed factors influencing students' decision to attend an RCS, including whether these factors were viewed as positive or negative. Open-ended questions provided students with an opportunity to make comments about their decision-making. The setting was the RCSs of six participating Australian universities. The participants were medical students enrolled at one of six Australian universities in 2006 (n=166) who had completed their RCS term; 125 students responded (75% response rate). RESULTS: At least three-quarters of the respondents considered the following when deciding whether to attend an RCS: patient access, academic reputation, their friends, the availability of subsidized accommodation provided by the clinical school, extra-curricular activities, social opportunities and transport costs. The majority of students considered the following as positive considerations: 'patient access', 'academic reputation', and 'subsidized accommodation'. However, for other students these same factors were negative considerations. CONCLUSION: Students consider both clinical and non-clinical factors in their decision to attend an RCS. The primary positive factor in the present study was patient access with 97% students (n=119) considering this to be important, and 84% students (n=81) stating that this was a positive factor in their decision-making. The other major factors, friends and academic reputation, appear equally considered. However, they differed in the degree to which they were regarded as a positive or negative consideration. Identifying and promoting positive factors is essential if the future rural medical workforce is to be enhanced. This study supports the importance of RCSs not being over-crowded and, thus, maintaining patient access, and also the importance of institutions having sufficient resources to support an excellent academic reputation. Interestingly, and perhaps somewhat contrary to expectations, students of metropolitan origin appear to be increasingly attracted to RCSs. Although numerous studies show that rural origin is a strong predictor of rural medical workforce membership, urban students who attend an RCS and have a positive experience may also be open to future rural practice.

Rural women and osteoporosis: awareness and educational needs.

CONTEXT: Little is known about rural women's knowledge about osteoporosis. PURPOSE: To explore what women from high-prevalence rural communities know about osteoporosis and to assess their learning preferences. METHODS: We surveyed 437 women in rural Washington and Oregon. FINDINGS: The response rate was 93% (N = 406). The mean age of respondents was 63 years (range 16-95) and 74% (n = 301) of women were postmenopausal. While 27% over age 40 (n = 111) reported having a fracture as an adult, less than half of this group (42%, n = 47) considered themselves at risk for osteoporosis. Of the 42% (n = 171) who rated their knowledge of osteoporosis good or excellent, only 18% (n = 30) answered calcium and vitamin D questions correctly. About half (53%; n = 214) exercised 3 or more times per week. Reported sources of osteoporosis information included television, magazines, health care providers, and personal contacts. Over half of the women in this study wanted more information about osteoporosis, most wanted it before age 50, and health care providers were a preferred source. Less than half of participants reported having Internet access. CONCLUSIONS: While many participants underestimated their osteoporosis risk, most women wanted to learn more about osteoporosis and health care providers remain a preferred source of information.

Incorporating medical students into your practice.

BACKGROUND: Teaching is fun and intrinsically rewarding. It helps doctors to refresh their knowledge base, improves morale, and adds variety to routine practice. However, it does take time. OBJECTIVE: This article discusses tips to help busy doctors incorporate learners into their practice. DISCUSSION: Many busy practitioners default to having the student 'sit in' on consultations. While this might be most efficient for the doctor, research on adult learning principles tell us that adults learn best when they are engaged and active in the learning process.

The Effect of Weight Loss on Indigenous Australians with Diabetes: a study of Feasibility, Acceptability and Effectiveness of Laparoscopic Adjustable Gastric Banding.

BACKGROUND/OBJECTIVES: Diabetes and obesity are common and serious health challenges for indigenous people worldwide. The feasibility of achieving substantial weight loss, leading to remission of diabetes, was evaluated in a regional indigenous Australian community. SUBJECTS/METHODS: A prospective cohort study of 30 obese indigenous adults from the Rumbalara Aboriginal Co-operative in Central Victoria was performed. Inclusion criteria included aboriginality, BMI > 30 kg/m(2) and diabetes diagnosed within the last 10 years. Weight loss was achieved using laparoscopic adjustable gastric banding (LAGB). Participants were treated in their community and followed for 2 years. Outcomes were compared with those of non-indigenous Australians from an earlier randomized controlled trial (RCT) using a similar protocol. RESULTS: 30 participants (26 females, mean age 44.6 years; mean BMI 44.3) had LAGB at the regional hospital. Twenty-six participants completed diabetes assessment at 2 years follow-up. They showed diabetes remission (fasting blood glucose < 7.0 mmol/L and haemoglobin A1c (HbA1c) < 6.2 % while off all therapy except metformin) in 20 of the 26 and a mean weight loss (SD) of 26.0 (14) kilograms. Based on intention-to-treat, remission rate was 66 %. Quality of life improved. There was one early event and 12 late adverse events. The outcomes for weight loss and diabetes remission were not different from the LAGB group of the RCT. CONCLUSIONS: For obese indigenous people with diabetes, a regionalized model of care centred on the LAGB is an effective approach to a serious health problem. The model proved feasible and acceptable to the indigenous people. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN 12609000319279).

Development of a common national questionnaire to evaluate student perceptions about the Australian Rural Clinical Schools Program.

The Australian Commonwealth Department of Health and Ageing provided funds for the Australian medical schools to establish Rural Clinical Schools. This workforce initiative has enabled medical students to learn in a diverse range of rural and remote healthcare settings. A common questionnaire was developed and agreed on by all the directors of the Rural Clinical Schools. Use of this common questionnaire will facilitate reports on student attitudes and program outcomes, both within individual Rural Clinical Schools and at a national program level. The data analysis will inform the community and the Australian Government about the effectiveness of the national Rural Clinical School program in (1) meeting the primary aims of providing high quality rural medical education; and (2) addressing the medical workforce shortage in rural and remote areas.

Postmenopausal hormone replacement therapy and major clinical outcomes: a focus on cardiovascular disease, osteoporosis, dementia, and breast and endometrial neoplasia.

Current data suggest that hormone replacement therapy (HRT) might have a beneficial role in the prevention of cardiovascular disease (CVD), osteoporosis, and dementia in postmenopausal women, but other therapies should be considered for the treatment of these conditions. In this review we evaluated the potential benefits of HRT for CVD, osteoporosis, and dementia, and compared HRT with proven, effective therapies. In addition, we identified the potential risks of breast and endometrial neoplasia, and an early risk of CVD and thromboembolic disease associated with HRT use.

The reported value of rural internal medicine residency electives and factors that influence rural career choice.

This study examines how rural electives affect medical residents' opinions about rural practice and which factors encourage or discourage choice of rural practice. Participants in a one- to two-month rural elective and a matched group of randomly selected nonparticipants were surveyed. Seventy percent of the elective participants (n = 58) and 61% of the matched nonparticipants (n = 51) completed the questionnaire. The groups' responses to scaled response measures and open-ended questions were analyzed using t , chi-square and Mann-Whitney U tests. A majority of participants stated that the elective was a beneficial experience (n = 36), and participants' interest in rural practice increased significantly after the elective. Elective participants were more likely than nonparticipants to see breadth of practice, continuity of care, quality of life in rural areas, and experiences with mentors as encouraging rural practice. Elective participation did not demonstrably increase rural career choice, although this finding may be attributable to small sample size. Respondents identified means to encourage rural practice, as well as barriers to rural practice: Elective participants suggested that electives may be more effective if they occurred earlier in medical training, lasted for longer periods of time, and addressed the needs of spouses or partners. Generalizability is limited by several factors, including small sample size and the possibility of pre-existing differences between elective participants and nonparticipants.

Common problems in outpatient management of patients with diabetes in the age of insulin analogues.

Most patients with diabetes are managed in an outpatient primary care setting. This article reviews common dilemmas in outpatient insulin therapy and presents the evidence regarding the rational use of insulin therapy and combination oral agent-insulin therapy.

Inpatient management of diabetes.

Hyperglycemia is common in hospitalized patients with diabetes and contributes to poor outcomes in this population. Use of intravenous insulin protocols for patients who are unable to eat, continuation of usual insulin regimens for those who are eating, pre-meal insulin supplements for hyperglycemia, and avoidance of sliding-scale insulin can help the clinician improve glycemic control. Careful attention to management of diabetes in the hospitalized patient decreases the risk of ketoacidosis, fluid and electrolyte abnormalities, and infection; in critically ill postoperative patients, tight glucose control with insulin administration decreases the risk of death.

Patient privacy versus protecting the patient and the health system from harm: a case study.

A 71-year-old man who presented to hospital with chest pain and a history of cardiovascular disease was repeatedly hospitalised over the course of a month for care that included multiple investigations, intensive care, transfer to and from a metropolitan hospital, discharge, and readmissions for collapse, hemiparesis, and vision change. The medical team excluded underlying disease related to his initial chest pain and subsequent neurological symptoms. A search for (undisclosed) prior hospitalisations revealed multiple previous admissions and invasive investigations at hospitals across Australia, resulting in a diagnosis of Munchausen syndrome. Assuming that, despite interventions, patients with Munchausen syndrome or somatoform disorders often continue to seek care at other hospitals, we discuss the implications of this patient's behaviour for the health care system, society, and the risk to his own health. In our view, this case highlights conflicts between privacy legislation and doctors' mandates to protect the patient from harm, as well as their duty to attend to the financial viability of health services by communicating with other potential health care providers. The health care system and similar patients may benefit from efforts to educate doctors about this spectrum of disorders and from considering the implementation of a highly confidential, structured notification system.

Medical students' reported barriers to training at a Rural Clinical School.

OBJECTIVE: To understand and address students' concerns about attending one of the new Commonwealth-funded Rural Clinical Schools. DESIGN: Analysis of students' reported reasons for clinical school selection from 2003 to 2004. SETTING: The School of Medicine and the Rural Clinical School, University of Melbourne. PARTICIPANTS: Data were obtained from de-identified preference documents submitted by the medical student cohort assigned to the University of Melbourne clinical schools to begin in July, 2004. RESULTS: Thirteen categories of student concerns (social) were identified from written student preference documents. CONCLUSIONS: Evaluation of the students' concerns about social dislocation if they were assigned to a rural clinical school has provided important information about perceived barriers to rural training. These issues must be systematically addressed at the school, university and community level.