Understanding medical students' transformative experiences of early preclinical international rural placement over a 20-year period.

INTRODUCTION: Rural placements are an important component of rural medical education programs seeking to develop rural practice pathways for medical students. These placements are usually domestic, but James Cook University in Australia developed an international rural placement program in the first half of the medical course that was funded through bursaries. This study explores how the international rural placement helped to shape the lives (personal development and learning) of the participants, using Transformational Learning Theory as a framework for identifying and describing the transformational elements, process and impact of the program. METHODS: Sixty-five students received a bursary for an international rural placement between 2001-2019. All were contacted by email and invited to participate in a short survey and a follow-up interview. Fifteen participants agreed and twelve were able to participate in individual semi-structured interviews which were recorded, transcribed and analysed using inductive thematic analysis. RESULTS: Participants reported that the bursary provided a "once in a lifetime opportunity" to "experience eye-opening and culturally rich difference". Nonetheless, some elements of the placement experience presented disorientating dilemmas that triggered deep reflections and shifts in perceptions. The bursary recipients realised that "being open-minded" allowed them "enjoy good company". They were also able to assume "outsider view which allowed reassessment of their own country" and the "isolation experiences gingered desire to right health wrongs". The triggers and mental shifts had significant impact on the bursary recipients and fostered the development of "inspirational new horizons" based on an appreciation of the "value of rural practice" and "role-modelling for life-long learning." These findings are consistent with Transformational Learning Theory. CONCLUSION: Participants in this study reported meaningful and strongly positive impacts from the experiences gained during an international rural clinical placement early in their course. They described transformative experiences which appear to contribute strongly to personal development. This finding supports maintaining opportunities for international experiences during rurally-oriented medical programs as these may impact longer term career choice.

Readiness to enter the workforce: perceptions of health professions students at a regional Australian university.

BACKGROUND: Perceived readiness for practice can help mitigate the stress and uncertainty associated with transitioning from university into the workforce. This study aimed to identify factors influencing the readiness for clinical practice among final-year medical, dental, and pharmacy students at an Australian regional university. METHODS: The study utilised a sequential explanatory mixed-methods approach with surveys administered for the quantitative phase and interviews/focus groups for the qualitative phase. Descriptive statistics and inductive thematic analysis were utilised for the quantitative and qualitative data, respectively. Triangulation of findings from both phases facilitated in-depth understanding of the factors that influenced participants' self-perceived readiness for clinical practice. RESULTS: From the three disciplines, 132 students completed the survey and 14 participated in the focus groups and interviews. Students felt most prepared in their patient-centred capabilities, core skills, and advanced consultation skills, and least prepared in their system-related capabilities and clinical care skills. Themes identified as essential enablers and confidence builders in relation to workforce readiness in all three disciplines were: gained knowledge and skills, value of clinical placement experiences, support from peers, family and staff. However, students felt their work-readiness was impaired by heavy academic workloads and poor knowledge of health care systems, which affected skills development. Participants suggested additional support in health care system and clinical governance, mental healthcare, and induction to placement sites to further improve their work readiness. CONCLUSIONS: The findings of this study suggest that improving work-readiness of healthcare students requires alignment of learning needs to real-world practice opportunities, ensuring support systems are appropriate, and early familiarisation with the healthcare system.

Preclinical to clinical transition experiences of dental students at an Australian Regional University.

INTRODUCTION: Clinical experience is a crucial component of dental education as it prepares students for real-world practice. Our study aimed to investigate the transition from preclinical to clinical training experiences of dental students at a regional Australian dental school. MATERIALS AND METHODS: A mixed-methods study was conducted using a survey and focus groups. Participants were dental students who recently transitioned into clinical training. Survey data were analysed quantitatively using descriptive statistics, whilst the qualitative data were thematically analysed using the conceptual framework of organisational socialisation theory (OST). RESULTS: Forty-eight of the 69 students in the cohort completed the survey and 10 participated in the focus groups. The quantitative findings revealed that the transition was perceived to be abrupt and associated with a heavy workload. However, orientation sessions and engaging in chairside teaching made transitioning into clinical studies easier. The qualitative findings revealed that the transition process occurred in three phases. In phase 1, participants navigated the educational and social challenges using developmental characteristics such as resilience and positivity. Lessons learnt in phase 1 were used to make necessary learning adjustments in phase 2 and this subsequently enhanced developmental growth in the final phase, which helped ease the transition. CONCLUSION: This study confirms that transitioning into clinical training can be complex. However, the educational and socialisation challenges associated with the transition can provide stimulating developmental learning opportunities that advance students' adjustments to the clinical environment with positive, empowering and motivational outcomes that facilitate a smooth transition.

Examiners' decision-making processes in observation-based clinical examinations.

BACKGROUND: Objective structured clinical examinations (OSCEs) are commonly used to assess the clinical skills of health professional students. Examiner judgement is one acknowledged source of variation in candidate marks. This paper reports an exploration of examiner decision making to better characterise the cognitive processes and workload associated with making judgements of clinical performance in exit-level OSCEs. METHODS: Fifty-five examiners for exit-level OSCEs at five Australian medical schools completed a NASA Task Load Index (TLX) measure of cognitive load and participated in focus group interviews immediately after the OSCE session. Discussions focused on how decisions were made for borderline and clear pass candidates. Interviews were transcribed, coded and thematically analysed. NASA TLX results were quantitatively analysed. RESULTS: Examiners self-reported higher cognitive workload levels when assessing a borderline candidate in comparison with a clear pass candidate. Further analysis revealed five major themes considered by examiners when marking candidate performance in an OSCE: (a) use of marking criteria as a source of reassurance; (b) difficulty adhering to the marking sheet under certain conditions; (c) demeanour of candidates; (d) patient safety, and (e) calibration using a mental construct of the 'mythical [prototypical] intern'. Examiners demonstrated particularly higher mental demand when assessing borderline compared to clear pass candidates. CONCLUSIONS: Examiners demonstrate that judging candidate performance is a complex, cognitively difficult task, particularly when performance is of borderline or lower standard. At programme exit level, examiners intuitively want to rate candidates against a construct of a prototypical graduate when marking criteria appear not to describe both what and how a passing candidate should demonstrate when completing clinical tasks. This construct should be shared, agreed upon and aligned with marking criteria to best guide examiner training and calibration. Achieving this integration may improve the accuracy and consistency of examiner judgements and reduce cognitive workload.

Developing a community of practice for quality assurance within healthcare assessment.

BACKGROUND: The Australian Collaboration for Clinical Assessment in Medicine (ACCLAiM) is a voluntary assessment consortium, involving medical schools nationwide. The aims of ACCLAiM are to benchmark student clinical assessment outcomes and to provide quality assurance (QA) of exit-level Objective Structured Clinical Exams (OSCEs). This study aimed to evaluate the impact of the ACCLAiM QA process for optimising OSCE delivery standards at the member schools using a Community of Practice (CoP) framework. METHODS: A mixed methods sequential explanatory design, involving an online questionnaire and subsequent focus group discussions, was utilised. Questionnaire responses were analysed using descriptive statistics, while thematic analysis was employed for the qualitative data. RESULTS: Data analysis revealed that school-specific OSCE practices had evolved based on QA feedback, as well as a collaborative sharing of expertise consistent with a CoP model. Extending beyond a QA working group for accountability and demonstration of minimum standards, participation in ACCLAiM QA processes is creating a sustainable socio-academic network focused on quality improvement. CONCLUSION: Collaborative QA in clinical assessment creates opportunities for optimising standards in OSCE processes and sharing of resources for OSCE assessments. It also allows for professional development and scholarly engagement in assessment research. These benefits contribute to the existence of an emergent CoP model.

Perceptions and processes influencing the transition of medical students from pre-clinical to clinical training.

BACKGROUND: The transition from pre-clinical to clinical medical training is often characterised by several challenges which may have different impacts on students' well-being and learning experiences. To ensure smooth transition, it's important to understand how these students navigate through the challenging processes. METHODS: This study employed a mixed-methods design using a survey, focus groups and interviews among medical students who had entered their first clinical year of study (Year 4). Using a 5-point Likert scale, survey participants rated items which related to their transition experience in the areas of professional socialisation; workload; patient contact; knowledge and skills; and learning and education. The qualitative questions explored challenges in transition, coping strategies and recommendations to foster smooth transitioning. The survey data was analysed using descriptive and inferential statistics while thematic analysis was used to establish emerging themes from the qualitative data. The Westerman Transition Framework was utilised in the triangulation of study findings. RESULTS: A total of 141 students participated in the survey while 12 students participated in the focus group discussions and interviews. The quantitative part of the study showed that the students were anxious about the process and considered the workload to be heavy while also identifying gaps in their knowledge. Similarly, the qualitative findings revealed that workload and professional socialisation were identified as disruptive novel elements and the students also reported feelings of inadequacy and incompetence due to perceived knowledge gaps. These shortcomings and challenges were tackled by seeking support from peers and senior medical students as a way of coping with the anxiety and stress. As the students progressed, they admitted and accepted that the transition was a gradual process and an essential learning curve. CONCLUSION: The process of transitioning from preclinical to clinical years is considered stressful and abrupt with the introduction of disruptive novel elements that create feelings of incompetence and unpreparedness in students. Educators need to consider developing social and developmental strategies that emphasise nurturing and empowering clinical learning environments and facilitate reflective and transformative life-long learning opportunities for students.

International overview of sea turtle fibropapillomatosis: a survey of expert opinions and trends.

Introduction: Marine environments offer a wealth of opportunities to improve understanding and treatment options for cancers, through insights into a range of fields from drug discovery to mechanistic insights. By applying One Health principles the knowledge obtained can benefit both human and animal populations, including marine species suffering from cancer. One such species is green sea turtles (Chelonia mydas), which are under threat from fibropapillomatosis (FP), an epizootic tumor disease (animal epidemic) that continues to spread and increase in prevalence globally. In order to effectively address this epizootic, a more thorough understanding is required of the prevalence of the disease and the approaches to treating afflicted turtles. Methods: To identify knowledge gaps and assess future needs, we conducted a survey of sea turtle FP experts. The survey consisted of 47 questions designed to assess general perceptions of FP, the areas where more information is needed, local FP trends, the disease status, and mitigation needs, and was voluntarily completed by 44 experts across a broad geographic range. Results: Over 70% of respondents both recognized FP as a cancerous panzootic disease, and reported that FP is increasing in prevalence. They report several factors contributing to this increase. Nearly all of the respondents reported that FP research, patient treatment and rehabilitation required more funding in their area, and reported inadequate facilities and capacity for dealing with FP patients. Treatment approaches varied: just over 70% of the medical experts that responded surgically remove FP tumors, either using laser or scalpel. Just under half of respondents use anti-cancer drugs in their treatment of FP. Internal tumors were reported as justification for euthanasia by 61.5% of respondents, and 30.8% reported severe external tumors to be sufficient grounds for euthanasia. Most medical respondents (93.3%) routinely perform necropsy on deceased or euthanized FP-afflicted turtles. Over 80% of respondents considered large-scale multidisciplinary collaboration 'extremely important' for advancing the field of FP research. Discussion: The survey responses provide a valuable insight into the current status of FP in sea turtles, FP treatment, rehabilitation and research, and help to identify critical FP-related areas most in need of attention.

Has the OSCE Met Its Final Demise? Rebalancing Clinical Assessment Approaches in the Peri-Pandemic World.

The Objective Structured Clinical Examination (OSCE) has been traditionally viewed as a highly valued tool for assessing clinical competence in health professions education. However, as the OSCE typically consists of a large-scale, face-to-face assessment activity, it has been variably criticized over recent years due to the extensive resourcing and relative expense required for delivery. Importantly, due to COVID-pandemic conditions and necessary health guidelines in 2020 and 2021, logistical issues inherent with OSCE delivery were exacerbated for many institutions across the globe. As a result, alternative clinical assessment strategies were employed to gather assessment datapoints to guide decision-making regarding student progression. Now, as communities learn to "live with COVID", health professions educators have the opportunity to consider what weight should be placed on the OSCE as a tool for clinical assessment in the peri-pandemic world. In order to elucidate this timely clinical assessment issue, this qualitative study utilized focus group discussions to explore the perceptions of 23 clinical assessment stakeholders (examiners, students, simulated patients and administrators) in relation to the future role of the traditional OSCE. Thematic analysis of the FG transcripts revealed four major themes in relation to participants' views on the future of the OSCE vis-a-vis other clinical assessments in this peri-pandemic climate. The identified themes are (a) enduring value of the OSCE; (b) OSCE tensions; (c) educational impact; and (d) the importance of programs of assessment. It is clear that the OSCE continues to play a role in clinical assessments due to its perceived fairness, standardization and ability to yield robust results. However, recent experiences have resulted in a diminishing and refining of its role alongside workplace-based assessments in the new, peri-pandemic programs of assessment. Future programs of assessment should consider the strategic positioning of the OSCE within the context of utilizing a range of tools when determining students' clinical competence.

Virtual OSCE Delivery and Quality Assurance During a Pandemic: Implications for the Future.

Background: During 2020, the COVID-19 pandemic caused worldwide disruption to the delivery of clinical assessments, requiring medicals schools to rapidly adjust their design of established tools. Derived from the traditional face-to-face Objective Structured Clinical Examination (OSCE), the virtual OSCE (vOSCE) was delivered online, using a range of school-dependent designs. The quality of these new formats was evaluated remotely through virtual quality assurance (vQA). This study synthesizes the vOSCE and vQA experiences of stakeholders from participating Australian medical schools based on a Quality framework. Methods: This study utilized a descriptive phenomenological qualitative design. Focus group discussions (FGD) were held with 23 stakeholders, including examiners, academics, simulated patients, professional staff, students and quality assurance examiners. The data was analyzed using a theory-driven conceptual Quality framework. Results: The vOSCE was perceived as a relatively fit-for purpose assessment during pandemic physical distancing mandates. Additionally, the vOSCE was identified as being value-for-money and was noted to provide procedural benefits which lead to an enhanced experience for those involved. However, despite being largely delivered fault-free, the current designs are considered limited in the scope of skills they can assess, and thus do not meet the established quality of the traditional OSCE. Conclusions: Whilst virtual clinical assessments are limited in their scope of assessing clinical competency when compared with the traditional OSCE, their integration into programs of assessment does, in fact, have significant potential. Scholarly review of stakeholder experiences has elucidated quality aspects that can inform iterative improvements to the design and implementation of future vOSCEs.

"Could You Work in My Team?": Exploring How Professional Clinical Role Expectations Influence Decision-Making of Assessors During Exit-Level Medical School OSCEs.

Decision-making in clinical assessment, such as exit-level medical school Objective Structured Clinical Examinations (OSCEs), is complex. This study utilized an empirical phenomenological qualitative approach with thematic analysis to explore OSCE assessors' perceptions of the concept of a "prototypical intern" expressed during focus group discussions. Topics discussed included the concept of a prototypical intern, qualities to be assessed, and approaches to clinical assessment decision-making. The thematic analysis was then applied to a theoretical framework (Cultural Historical Activity Theory-CHAT) that explored the complexity of making assessment decisions amidst potentially contradicting pressures from academic and clinical perspectives. Ten Australasian medical schools were involved with 15 experienced and five less experienced assessors participating. Thematic analysis of the data revealed four major themes in relation to how the prototypical intern concept influences clinical assessors' judgements: (a) Suitability of marking rubric based on assessor characteristics and expectations; (b) Competence as final year student vs. performance as a prototypical intern; (c) Safety, trustworthiness and reliability as constructs requiring assessment and (d) Contradictions in decision making process due to assessor differences. These themes mapped well within the interaction between two proposed activity systems in the CHAT model: academic and clinical. More clinically engaged and more experienced assessors tend to fall back on a heuristic, mental construct of a "prototypical intern," to calibrate judgements, particularly, in difficult situations. Further research is needed to explore whether consensus on desirable intern qualities and their inclusion into OSCE marksheets decreases the cognitive load and increases the validity of assessor decision making.

The Concurrent Detection of Chelonid Alphaherpesvirus 5 and Chelonia mydas Papillomavirus 1 in Tumoured and Non-Tumoured Green Turtles.

Characterised by benign tumours, fibropapillomatosis (FP) is a debilitating disease that predominantly afflicts the endangered green turtle (Chelonia mydas). A growing body of histological and molecular evidence has associated FP tumours with Chelonid alphaherpesvirus 5 (ChHV5). However, a recent study which detected both ChHV5 and Chelonia mydas papillomavirus 1 (CmPV1) DNA in FP tumour tissues has challenged this hypothesis. The present study aimed to establish a probe-based qPCR to assess the wider prevalence of CmPV1 and co-occurrence with ChHV5 in 275 marine turtles foraging in waters adjacent to the east coast of Queensland, Australia: three categories: Group A (FP tumours), Group B (non-tumoured skin from FP turtles) and Group C (non-tumoured skin from turtles without FP). Concurrent detection of ChHV5 and CmPV1 DNA is reported for all three categories, where Group A had the highest rate (43.5%). ChHV5 viral loads in Group A were significantly higher than loads seen in Group B and C. This was not the case for CmPV1 where the loads in Group B were highest, followed by Group A. However, the mean CmPV1 load for Group A samples was not significantly different to the mean load reported from Group B or C samples. Collectively, these results pivot the way we think about FP; as an infectious disease where two separate viruses may be at play.

Adjusting to university: Perceptions of first-year health professions students.

BACKGROUND: The transition experience into university can be challenging for health profession students as they are required to rapidly learn diverse and adaptable problem solving skills and advanced reflective thinking processes which are necessary to address complex patient-care problems, particularly in the face of uncertainty within a dynamic and rapidly evolving learning environment. METHODS: A mixed-methods study was conducted to identify factors influencing this transition for first-year medical, dental, and pharmacy students at a regional Australian university. The Student Adaption to College Questionnaire (SACQ) examined participants' levels of adjustment to university, while Schlossberg's 4 S transition model was utilised in a framework analysis of the focus group and interview responses. RESULTS: Complete survey responses were obtained from 198 students, 17 of whom also participated in focus group discussions or interviews. Mean adjustment ratings obtained from the SACQ responses were academic (6.09 ± 1.3) personal-emotional (5.53 ± 1.55), social (6.30 ± 1.38), and institutional attachment (6.96 ± 1.6). These results indicate that the personal and emotional aspects of this transition were more challenging for the students. Analysis of the qualitative data revealed that generally, for these highly motivated health-professions students, dropping out of university was not an option and this had a positive influence on their ability to adjust to their new learning environment. Nonetheless, the transition involved role change; school-leavers were excited about their newly found independence, while for mature-aged students, returning to university allowed them to pursue their lifelong dreams. Adjustment was more challenging for international, mature-aged and female students, with personal and social factors influencing the transition for each of these demographic groups. CONCLUSIONS: To facilitate smooth transition into university, tertiary education institutions must consider tailored on-going support strategies that promote social interaction among students with varied backgrounds and personal characteristics.

Disease risk analysis in sea turtles: A baseline study to inform conservation efforts.

The impact of a range of different threats has resulted in the listing of six out of seven sea turtle species on the IUCN Red List of endangered species. Disease risk analysis (DRA) tools are designed to provide objective, repeatable and documented assessment of the disease risks for a population and measures to reduce these risks through management options. To the best of our knowledge, DRAs have not previously been published for sea turtles, although disease is reported to contribute to sea turtle population decline. Here, a comprehensive list of health hazards is provided for all seven species of sea turtles. The possible risk these hazards pose to the health of sea turtles were assessed and "One Health" aspects of interacting with sea turtles were also investigated. The risk assessment was undertaken in collaboration with more than 30 experts in the field including veterinarians, microbiologists, social scientists, epidemiologists and stakeholders, in the form of two international workshops and one local workshop. The general finding of the DRA was the distinct lack of knowledge regarding a link between the presence of pathogens and diseases manifestation in sea turtles. A higher rate of disease in immunocompromised individuals was repeatedly reported and a possible link between immunosuppression and environmental contaminants as a result of anthropogenic influences was suggested. Society based conservation initiatives and as a result the cultural and social aspect of interacting with sea turtles appeared to need more attention and research. A risk management workshop was carried out to acquire the insights of local policy makers about management options for the risks relevant to Queensland and the options were evaluated considering their feasibility and effectiveness. The sea turtle DRA presented here, is a structured guide for future risk assessments to be used in specific scenarios such as translocation and head-starting programs.

Fibropapillomatosis in a Green Sea Turtle ( Chelonia mydas) from the Southeastern Pacific.

Fibropapillomatosis is a neoplastic disease that afflicts sea turtles. Although it is disseminated worldwide, cases of the disease have not been reported in the southeastern Pacific region. We describe a case of fibropapillomatosis in a green sea turtle ( Chelonia mydas) during its rehabilitation at the Machalilla National Park Rehabilitation Center, Ecuador. Viral presence was confirmed by PCR, targeting fragments of the chelonid alphaherpesvirus 5 (ChHV5) unique long (UL) genes, UL27, UL28, and UL30. The amplicons were sequenced and included in a global phylogenetic analysis of the virus with other reported sequences from GenBank. Results showed that the available viral sequences segregated into five phylogeographic groups: western Atlantic and eastern Caribbean, central Pacific, western Pacific, Atlantic, and eastern Pacific groups. The concatenated ChHV5 sequences from Ecuador clustered with the eastern Pacific sequences.

Closing the gap: mixed stock analysis of three foraging populations of green turtles (Chelonia mydas) on the Great Barrier Reef.

A solid understanding of the spatial ecology of green turtles (Chelonia mydas) is fundamental to their effective conservation. Yet this species, like many marine migratory species, is challenging to monitor and manage because they utilise a variety of habitats that span wide spatio-temporal scales. To further elucidate the connectivity between green turtle rookeries and foraging populations, we sequenced the mtDNA control region of 278 turtles across three foraging sites from the northern Great Barrier Reef (GBR) spanning more than 330 km: Cockle Bay, Green Island and Low Isles. This was performed with a newly developed assay, which targets a longer fragment of mtDNA than previous studies. We used a mixed stock analysis (MSA), which utilises genetic data to estimate the relative proportion of genetically distinct breeding populations found at a given foraging ground. Haplotype and nucleotide diversity was also assessed. A total of 35 haplotypes were identified across all sites, 13 of which had not been found previously in any rookery. The MSA showed that the northern GBR (nGBR), Coral Sea (CS), southern GBR (sGBR) and New Caledonia (NC) stocks supplied the bulk of the turtles at all three sites, with small contributions from other rookeries in the region. Stock contribution shifted gradually from north to south, although sGBR/CS stock dominated at all three sites. The major change in composition occured between Cockle Bay and Low Isles. Our findings, together with other recent studies in this field, show that stock composition shifts with latitude as a natural progression along a coastal gradient. This phenomenon is likely to be the result of ocean currents influencing both post-hatchling dispersal and subsequent juvenile recruitment to diverse coastal foraging sites.