Leasing a medical curriculum: What's it worth?

Introduction: The early part of this century saw an unprecedented growth in number and size of Australian medical schools. There was some partnering of the new schools with existing programs. Griffith, Deakin and Curtin Universities leased an established curriculum from Flinders University. Nature and rationale for curriculum leasing: The new schools had short startup times and leasing a curriculum enabled them to appoint key staff, develop facilities and meet accreditation requirements in a timely way. However, the lease arrangements were costly and the curriculum was largely determined before the Dean and key staff appointments. Outcomes of leasing: There was differential adoption of the leased curriculum. The first two years of the courses at Flinders were transferred with little change. The final two years of predominantly clinical studies were developed differently. This is explained through Michael Fullan's work on context in educational change. The context of the clinical years of the courses involved negotiations with local health services and other schools using those health services. The advantage of the leasing arrangements was that the new schools could proceed through early development and accreditation, while having time and opportunity to negotiate a clinical curriculum that engaged local health services and fulfilled the new schools' missions.

Barriers and enablers to emergency department nurses' management of patients' pain.

Pain is the most common reason for presentation to the emergency department (ED). On presentation patients expect rapid pain relief, yet this is often not met. Despite extensive improvements in analgesia medication there are still barriers to nurses' assessment, management, documentation, and reassessment of pain. The aim of this study is to identify barriers, enablers, and current nursing knowledge regarding pain management. Using an anonymous quantitative web-based survey, members of the College of Emergency Nurses New Zealand were invited to complete a questionnaire on pain assessment and management. The questionnaires were analyzed using descriptive statistics. Enablers to ED nurses' improved management of pain were the provision of nurse-initiated analgesic protocols and pain management champions. Common barriers perceived by the respondents were the responsibility of caring for acutely ill patients as well as a patient with pain. Similar barriers to previous research were identified and included lack of time, workload, reluctance of clinicians to prescribe analgesia, and the lack of nursing knowledge regarding opioid administration. Raising awareness that oligoanalgesia exists in the ED is essential. This research suggested that nurses would benefit from ongoing education on the usage of opioids. Nurses' attitude regarding patients' right to expect total pain relief as a consequence of treatment was also an issue. ED nurses, by virtue of their role, are in a unique position to be leaders in pain assessment and pain management.

Environments for Healthy Living (EFHL) Griffith birth cohort study: background and methods.

The health of an individual is determined by the interaction of genetic and individual factors with wider social and environmental elements. Public health approaches to improving the health of disadvantaged populations will be most effective if they optimise influences at each of these levels, particularly in the early part of the life course. In order to better ascertain the relative contribution of these multi-level determinants there is a need for robust studies, longitudinal and prospective in nature, that examine individual, familial, social and environmental exposures. This paper describes the study background and methods, as it has been implemented in an Australian birth cohort study, Environments for Healthy Living (EFHL): The Griffith Study of Population Health. EFHL is a prospective, multi-level, multi-year longitudinal birth cohort study, designed to collect information from before birth through to adulthood across a spectrum of eco-epidemiological factors, including genetic material from cord-blood samples at birth, individual and familial factors, to spatial data on the living environment. EFHL commenced the pilot phase of recruitment in 2006 and open recruitment in 2007, with a target sample size of 4000 mother/infant dyads. Detailed information on each participant is obtained at birth, 12-months, 3-years, 5-years and subsequent three to five yearly intervals. The findings of this research will provide detailed evidence on the relative contribution of multi-level determinants of health, which can be used to inform social policy and intervention strategies that will facilitate healthy behaviours and choices across sub-populations.

Why are junior doctors deterred from choosing a surgical career?

OBJECTIVE: To identify the reasons why interns would not choose a surgical career. METHODS: This qualitative study used semi-structured telephone interviews to explore the future career choices of 41 junior doctors (14 men, 27 women). Doctors were asked to identify specialties they would not take up, and state why this was the case. RESULTS: Thirty (73.2%) of the 41 interns nominated surgery as a specialty they would not choose. Themes relating to reasons for not wanting to pursue a surgical career included the lifestyle associated with surgery (66.7%), the culture within the surgical work environment (53.3%), the lack of interest in performing surgical work (36.7%), and the training requirements associated with surgery (33.3%). Both sexes had similar reasons for not wanting to choose a surgical career; but additionally, women referred to the male domination of surgery, and the difficulty and inflexibility of the training program as deterrents. CONCLUSIONS: Efforts are needed to promote interest in surgery as a career especially for women, to improve the surgical work environment so that medical students and junior doctors have exposure to positive role models and surgical placements, and to provide a more flexible approach to surgical training.

Junior doctors' and medical students' commitment to working in areas of workforce shortage.

INTRODUCTION: Australian Government initiatives promote rural training placements, supported medical school places, and incentives that attract doctors to areas of need. The purpose of this study was to report on the preparedness of medical students and junior doctors to commit to working in areas of workforce shortage. METHODS: Medical students and junior doctors across all Australian states and territories completed a web-based survey assessing career attitudes and intentions. Participants were asked to indicate their level of preparedness to commit to working in an area of need. RESULTS: Completed surveys were received from 760 medical students and 264 junior doctors. A substantial proportion of this sample were prepared to make some form of commitment to providing medical services in a rural area. The greatest proportion (38.3%) was prepared to make a small commitment equal to an irregular locum service of 1 week or 1 month per year. CONCLUSION: Government policies and incentives may be having an effect on medical students' and junior doctors' preparedness to work in rural and remote areas. Medical educators should encourage students and junior doctors to take up short-term placements/opportunities and to maintain links with rural communities. Practice opportunities that offer varying lengths of commitment should be advertised widely so junior doctors are aware of them and can apply.

Risk factors and obstetric complications of large for gestational age births with adjustments for community effects: results from a new cohort study.

BACKGROUND: High birth weight has serious adverse impacts on chronic health conditions and development in children. This study identifies the social determinants and obstetric complications of high birth weight adjusted for gestational age and baby gender. METHODS: Pregnant women were recruited from three maternity hospitals in South-East Queensland in Australia during antenatal clinic visits. A questionnaire was completed by each participant to elicit information on eco-epidemiological exposures. Perinatal information was extracted from hospital birth records. A hierarchical mixture regression model was used in the analysis to account for the heterogeneity of birth weights and identify risk factors and obstetric complications of births that were large for gestational age. A generalized linear mixed model was used to adjust for (random) "community" effects. RESULTS: Pre-pregnancy obesity (adjusted OR = 2.73, 95% CI = 1.49-5.01), previous pregnancy (adjusted OR = 2.03, 95% CI = 1.08-3.81), and married mothers (adjusted OR = 1.85, 95% CI = 1.00-3.42) were significantly associated with large for gestational age babies. Subsequent complications included the increased need for delivery by caesarean sections or instrumental procedures (adjusted OR = 1.98, 95% CI = 1.10-3.55), resuscitation (adjusted OR = 2.52, 95% CI = 1.33-4.79), and transfer to intensive/special care nursery (adjusted OR = 3.76, 95% CI = 1.89-7.49). Communities associated with a higher proportion of large for gestational age births were identified. CONCLUSIONS: Pre pregnancy obesity is the principal modifiable risk factor for large for gestational age births. Large for gestational age is an important risk factor for the subsequent obstetric complications. The findings improve the evidence-base on which to base preventive interventions to reduce the impact of high birth weight on maternal and child health.

Why do junior doctors not want to work in a rural location, and what would induce them to do so?

OBJECTIVE: Identify the most important factors associated with choosing rural medical practice. DESIGN: Cross-sectional design using a web survey to collect quantitative and qualitative data. PARTICIPANTS: One hundred and ninety junior doctors--91 interns, 99 PGY2. MAIN OUTCOME MEASURES: Choice of practice location (urban/rural), reason for choosing location, enticement to a rural location. RESULTS: Twenty-seven per cent of junior doctors preferred a rural practice location. Preference to practice in a rural area was associated with medical placement bonding schemes, rural background, rural placement experience and being older. High levels of professional expectations and prestige were associated with a preference for an urban location. The most important reasons for choosing a practice location included consideration of partner, family and friends (35.3%), preference for a location (20.5%), lifestyle goals (19.5%) and career opportunities, specialty requirements and infrastructure (17.9%). Those who preferred an urban compared with a rural location gave more importance to factors concerning partner, family and friends. The factors that would entice a doctor to a rural location included partner and family considerations (27.0%), professional support (20.3%), and career opportunities, specialty requirements and infrastructure (16.3%). Women gave more importance to partner and family factors than men. CONCLUSIONS: Our findings support the continuation of policies that are known to encourage choice of rural practice, but highlight the need for additional strategies that consider the personal and professional needs of this generation of doctors.

Developments in pharmacists' disciplinary processes and outcomes.

Pharmacy disciplinary processes and outcomes protect consumers by deterring pharmacists from unacceptable practices and maintaining the reputation and standing of the pharmacy profession. It is important that pharmacists are informed of disciplinary processes and outcomes in order to predict what is regarded as unacceptable behaviour and the potential consequences thereof. Disciplinary procedures and outcomes also play an important role in maintaining public trust in the pharmacy profession and it is therefore important that the public has confidence in the disciplinary structure. The outcomes of pharmacy disciplinary cases that reflect the patient care role of pharmacists are particularly important in helping to determine pharmacists' changed professional responsibility and potential legal liability in the provision of these patient care services.

Pharmacy practice developments: the potential impact on pharmacists' legal liability.

The practice of pharmacy has changed over recent years with a greater emphasis on the patient and the provision of patient care services. This expanded role of pharmacists as medication managers has resulted in changes to their professional responsibility and potential legal liability. Recent international case law demonstrates an increased legal liability of pharmacists in certain instances. However, pharmacists' liability in this new context in Australia is yet to be clarified.

The information needs of patients receiving procedural sedation in a hospital emergency department.

This research investigated the information needs of patients receiving ED procedural sedation to determine the best format to consistently deliver key information in a way acceptable to all involved. Of particular interest was the question concerning patients' need for receiving written information. A descriptive exploratory study gathered qualitative data through face-to-face interviews and focus groups involving patients, nurses and medical staff. Individual interviews were conducted with eight adult patients following procedural sedation. They identified very few gaps in terms of specific information they needed pertaining to procedural sedation and rejected the need for receiving information in a written format. Their information needs related to a central concern for safety and trust. Focus groups, reflecting on the findings from patients, were conducted with five ED nurses and four emergency medicine consultants/registrars who regularly provided procedural sedation. Themes that emerged from the analysis of data from all three groups identified the issues concerning patient information needs as being: competence and efficiency of staff; explanations of procedures and progress; support person presence; and medico-legal issues. The research confirms that the quality of the patient's ED experience, specifically related to procedural sedation, is enhanced by ED staff, especially nurses, providing them with ongoing and repeated verbal information relevant to their circumstances.

Exercise treadmill tests in patients with low cardiovascular risk: are we wasting our time?

INTRODUCTION The efficacy and cost-effectiveness of exercise treadmill testing for patients with low cardiovascular risk is unclear. This is due to the low incidence of coronary artery disease in this population and the potential for false-positive results leading to additional invasive and expensive investigation. AIM To investigate the value of exercise treadmill testing (ETT) as a predictor of coronary artery disease in patients with different levels of cardiovascular risk. METHODS An observational study was completed on an outpatient population from a chest pain clinic (n = 529). Cross-tabulations and binary logistic regressions were used to examine relationships between variables. RESULTS A negative ETT result was recorded for 72.5% of patients with low cardiovascular risk compared to 54.3% of those with moderate or high risk. Within the low cardiovascular risk group, patients with symptoms atypical for cardiac ischaemia were 11.1-fold more likely to have a negative ETT result. Of the patients with positive or equivocal ETT results, coronary artery disease was subsequently confirmed in only 23.1% of the low cardiovascular risk group compared to 77.2% of those with moderate or high cardiovascular risk. DISCUSSION Results show low cardiovascular risk patients are significantly more likely to return negative ETT results, particularly when associated with atypical symptoms. Similarly, positive or equivocal ETTs in this group are significantly more likely to be false positives. This suggests the ETT is not efficacious in predicting coronary artery disease in patients with low cardiovascular risk. Is it therefore appropriate to offer exercise testing to this cohort or should alternative management strategies be considered?

Medical specialty prestige and lifestyle preferences for medical students.

In the context of doctor shortages and mal-distributions in many Western countries, prestige and lifestyle friendliness have emerged as significant factors for medical students when they choose a medical specialty. In this study, we surveyed two samples of Australian medical students and had them rank 19 medical specialties for prestige (N = 530) and lifestyle friendliness (N = 644). The prestige rankings were generally consistent with previous ratings by physicians, lay people and advanced medical students, with surgery, internal, and intensive care medicine ranking the highest, and public health, occupational, and non-specialist hospital medicine ranking lowest. This suggests that medical students have incorporated prevailing prestige perceptions of practicing doctors and the community. Lifestyle rankings were markedly different from prestige rankings, where dermatology, general practice, and public health medicine were ranked the most lifestyle friendly, and surgery, obstetrics/gynaecology and intensive care were ranked least friendly. Student lifestyle rankings differed from physician and author-generated rankings, indicating that student preferences should be considered rather than relying on ratings created by others. Few differences were found for gender or year of study, signifying perceptions of prestige and lifestyle friendliness were consistent across the students sampled. Having access to and understanding these rankings will assist career counsellors to aid student and junior doctor decision-making and aid workforce planners to address gaps in medical specialty health services.

Assessing suitability for a problem-based learning curriculum: evaluating a new student selection instrument.

CONTEXT: A new student selection instrument has been designed to assess candidate suitability for a problem-based learning, small group curriculum. OBJECTIVE: To evaluate the performance of the new teamwork selection instrument in terms of its discriminatory power, fairness, validity, reliability and acceptability among candidates. SAMPLE: A sample of 69 volunteer candidates attending for interview formed 13 teams of 5 or 6 candidates each. Each candidate was assessed independently by 2 assessors. Candidate performance in the exercise was used for instrument evaluation purposes only. RESULTS: The instrument demonstrated good item discrimination (item-total correlations r = between 0.75 and 0.83, P <0.01); the potential for good agreement between raters (63% agreement, weighted kappa = 0.38, P <0.01); strong internal consistency reliability (Cronbach's alpha = 0.93), and good acceptability among candidates. No sources of assessment bias were identified on the basis of candidates' age (univariate anova F = 0.43, P >0.05), gender (unrelated samples t-test F = 1.2, P >0.05) or socioeconomic background (univariate anova F = 0.85, P >0.05). There was no statistically significant relationship between the candidates' performance in the new exercise and their performance in the standardised formal interview (r = - 0.37, P >0.05); the instrument had limited predictive validity, and some of the measured attributes require conceptual clarification. Discussion Statistical and conceptual analysis highlights the scope for development in the teamwork exercise. The exercise appears to be well suited to assessing candidate suitability for a problem-based learning curriculum.

Assessment of progress tests.

BACKGROUND: Progress testing is a form of longitudinal examination which, in principle, samples at regular intervals from the complete domain of knowledge considered a requirement for medical students on completion of the undergraduate programme. Over the course of the programme students improve their scores on the test, enabling them, as well as staff, to monitor their progress. AIM: We aimed to review methods which have been used to assess the results of individual tests, and to make recommendations on best practice. DISCUSSION: In assessing progress tests, there are a variety of choices that must be made. These include whether the test is norm- or criterion-referenced; whether marking is negative or "number-right"; whether the grades are reported on a continuous or a discontinuous scale, and whether the grades are weighted towards the most recent observations, or the entire set of grades is used to determine the final grade. Grade boundary setting in the context of progress tests is also considered, using a mathematical model to predict the consequences of different approaches. The relationships between boundary setting, progression and remediation rules are considered. CONCLUSIONS: We concluded that norm referencing is preferable to criterion referencing, negative marking preferable to number-right marking, a discontinuous scale preferable to a continuous scale and that grades should be weighted to favour the most recent outcomes, although there should still be a degree of persistence (earlier grades should not disappear all together). Grade boundaries should be established with regard to rules on remediation and progression.

Selection for medical school: just pick the right students and the rest is easy!

BACKGROUND/AIMS: The new Peninsula Medical School (PMS) admitted its first undergraduate cohort in September 2002. Development of a new school has given rise to opportunities for critical appraisal of best practice in selecting students for medical school and development of new ways forward. METHODS: The authors developed a selection strategy and principles grounded in the objectives of the PMS programme and drawing extensively on best practice in assessment. Critical appraisal of custom and practice amongst other UK medical schools led to the rejection of hitherto commonly used instruments and procedures and the development of new ones. Common assumptions about ways to ensure quality were also challenged. RESULTS: A process for development of an evidence-based selection strategy is described. In addition, selection instruments and criteria to be used in a new medical school are discussed. Quality performance policies informed by psychometric and qualitative assessment performance measures are recommended. DISCUSSION AND CONCLUSION: Critical appraisal of custom and practice and the development of new strategies, criteria and selection instruments go only part way to informing best practice. As with other UK medical schools grappling with these issues, the test of these selection processes lies in their product.

Teaching anatomy without cadavers.

BACKGROUND: Anatomy learning is generally seen as essential to medicine, and exposure to cadavers is generally seen as essential to anatomy learning around the world. Few voices dissenting from these propositions can be identified. AIMS: This paper aims to consider arguments relating to the use of cadavers in anatomy teaching, and to describe the rationale behind the decision of a new UK medical school not to use cadaveric material. DISCUSSION: First, the background to use of cadavers in anatomy learning is explored, and some general educational principles are explored. Next, arguments for the use of human cadaveric material are summarised. Then, possible arguments against use of cadavers, including educational principles as well as costs, hazards and practicality, are considered. These are much less well explored in the existing literature. Next, the rationale behind the decision of a new UK medical school not to use cadaveric material is indicated, and the programme of anatomy teaching to be employed in the absence of the use of human remains is described. Curriculum design and development, and evaluation procedures, are briefly described. Issues surrounding pathology training by autopsy, and postgraduate training in surgical anatomy, are not addressed in this paper. FUTURE DIRECTIONS: Evidence relating to the effect on medical learning by students not exposed to cadavers is scant, and plainly opportunities will now arise through our programme to gather such evidence. We anticipate that this discussion paper will contribute to an ongoing debate, in which virtually all previous papers on this topic have concluded that use of cadavers is essential to medical learning.