Power and place: Uncovering the politics of global medical education.

CONTEXT: Politics is characterised by power relations, and the deployment of power is inescapably political. In an increasingly globalised and interconnected modern world, politics is shaping the field of medical education more than ever before. Global frameworks that classify peoples and places are political tools that are fundamentally shaped by hegemonic knowledge systems. Despite this, they continue to form the basis for global thinking and practices, including in medical education. Political analysis can help to expose and challenge such thinking. APPROACH: To better understand impacts of globalisation in medical education, we explore the previously under-examined political dimensions that underpin it, focusing particularly on deconstructing power relations. We situate our analysis of global medical education in political terms, including through examination of ideology, economics, market and the enduring effects of colonialism. We interrogate the construct of the Global South (GS), considering the geopolitical and historical ideas that have enabled it to be widely propagated. We go on to examine the consequences of the GS construct in medical education and consider what this tells us about how power is enacted in the field. CONCLUSIONS: In analysing the politics of global medical education, we shed light on how power is exerted and draw attention to forces that permit and enable trends, policies and positions. Notwithstanding the emancipatory rhetoric that has been associated with the GS construct, we highlight its reductive potential and argue that it can lead to an oversimplification of power relations and vested interests. Given the growing recognition that educational approaches do not transfer well across countries and cultures, we encourage the medical education community to consider why ideas from more dominant countries continue to be imitated so routinely. In doing so, we urge them to use political lenses to recognise the influence of multiple complex and interconnected forces of global power that shape all aspects of medical education.

Insights from semi-structured interviews on integrating artificial intelligence in clinical chemistry laboratory practices.

BACKGROUND: Artificial intelligence (AI) is gradually transforming the practises of healthcare providers. Over the last two decades, the advent of AI into numerous aspects of pathology has opened transformative possibilities in how we practise laboratory medicine. Objectives of this study were to explore how AI could impact the clinical practices of professionals working in Clinical Chemistry laboratories, while also identifying effective strategies in medical education to facilitate the required changes. METHODS: From March to August 2022, an exploratory qualitative study was conducted at the Section of Clinical Chemistry, Department of Pathology and Laboratory Medicine, Aga Khan University, Karachi, Pakistan, in collaboration with Keele University, Newcastle, United Kingdom. Semi-structured interviews were conducted to collect information from diverse group of professionals working in Clinical Chemistry laboratories. All interviews were audio recorded and transcribed verbatim. They were asked what changes AI would involve in the laboratory, what resources would be necessary, and how medical education would assist them in adapting to the change. A content analysis was conducted, resulting in the development of codes and themes based on the analyzed data. RESULTS: The interviews were analysed to identify three primary themes: perspectives and considerations for AI adoption, educational and curriculum adjustments, and implementation techniques. Although the use of diagnostic algorithms is currently limited in Pakistani Clinical Chemistry laboratories, the application of AI is expanding. All thirteen participants stated their reasons for being hesitant to use AI. Participants stressed the importance of critical aspects for effective AI deployment, the need of a collaborative integrative approach, and the need for constant horizon scanning to keep up with AI developments. CONCLUSIONS: Three primary themes related to AI adoption were identified: perspectives and considerations, educational and curriculum adjustments, and implementation techniques. The study's findings give a sound foundation for making suggestions to clinical laboratories, scientific bodies, and national and international Clinical Chemistry and laboratory medicine organisations on how to manage pathologists' shifting practises because of AI.

Quality and constructed knowledge: Truth, paradigms, and the state of the science.

CONTEXT AND TRUTH: Education is a social science. Social science knowledge is related to its context of origin. The concept of global 'truth' in education is therefore of limited use when truth is tempered by context. The wider applicability of our knowledge can only be judged if we look at the context in which that knowledge was produced and the assumptions that underpin it. This calls into question the idea that educational research is a quest for global 'truth', although in relation to programme evaluation, truth tied to context is an aim. An analysis is presented of the effects of social construction on research and evaluation processes, on the selection of paradigms, reporting and interpreting findings, and on the ethics of all this. QUALITY AND IMPROVEMENT: Quality improvement is based on information selected, constructed and interpreted by those who gather, analyse or use it. The strength, and not the weakness, of our knowledge is that it is socially constructed, contextual and of its time. Increasingly looking for our own truth about educational quality, and not importing the truth of others, is crucial to the state of the science. In terms of quality development, using others' findings must be based on informed local judgement. In social science, those judgements are linked to social context and their associated ideologies. IMPLICATIONS FOR FUTURE WORK: The hallmark of social science is not a narrowing of focus and the search for one truth, but is a broadening of concepts, theories, paradigms, reported experience and method, and an intention for each to tell their own truth well. This will lead to a wealth of diverse views and analysed experience. The science of medical education must seek many truths.

Temporary Migration for Training: A Special Case.

BACKGROUND: Against a background of globalization and medical migration, issues have been raised regarding training outside the clinician's own context. OBJECTIVE: There is a dearth of published literature on these issues and we aimed to explore these. METHODS: Taking Chang Gung Memorial Hospital fellowships in microfacial and craniofacial surgery as our case study, we developed an online survey to look at the circumstances leading junior doctors to seek specific, high-level training outside their country of intended practice and how effective this was for their future career, the service they provide, and their institutions. RESULTS: Fellows come to the Chang Gung Memorial Hospital predominantly from Europe, North America, and Asia, rather than specifically from developing countries. The predominant reasons were professional, personal, and to gain training that was not available at home, followed by career development. The fellowship was not commonly used as a career step or a means of migration. Our results showed that most fellows received training that enabled them to provide a service for complex cases on returning to their home country. Implementing newly acquired skills at home did not present any consistent challenges for fellows. CONCLUSIONS: This study addressed a new phenomenon for the literature on medical migration: temporary migration from developed countries for the purposes of training and not permanent migration. The motivation for seeking these fellowships was to make up for training opportunities that were not available in highly planned health economies. To develop their practice in their home institutions, fellows often had to make adjustments to ensure effective transfer of skills and, in doing so, contribute to service development.

The association between gastroesophageal reflux disease with sleep quality, depression, and anxiety in a cohort study of Australian men.

BACKGROUND AND AIM: Previous clinical studies have demonstrated a relationship between gastroesophageal reflux disease (GERD) with anxiety and depression; however, few population-based studies have controlled for sleep disorders. The current study aimed to assess the relationship between GERD and anxiety, depression, and sleep disorders in a community-based sample of Australian men. METHODS: Participants comprised a subset of 1612 men (mean age: 60.7 years, range: 35-80) who participated in the Men Androgen Inflammation Lifestyle Environment and Stress Study during the years 2001-2012, who had complete GERD measures (Gastresophageal Reflux Disease Questionnaire), and were not taking medications known to impact gastrointestinal function (excluding drugs taken for acid-related disorders). Current depression and anxiety were defined by (i) physician diagnosis, (ii) symptoms of depression (Beck Depression Inventory and Centre for Epidemiological Studies Depression Scale) or anxiety (Generalized Anxiety Disorder-7), and/or current depressive or anxiolytic medication use. Previous depression was indicated by past depressive diagnoses/medication use. Data on sleep quality, daytime sleepiness, and obstructive sleep apnea were collected along with several health, lifestyle, and medical factors, and these were systematically evaluated in both univariate and multivariable analyses. RESULTS: Overall, 13.7% (n = 221) men had clinically significant GERD symptoms. In the adjusted models, an association between GERD and anxiety (odds ratio [OR] 2.7; 95% confidence interval [CI] 1.0-6.8) and poor sleep quality (OR 1.8; 95% CI 1.2-2.9) was observed; however, no effect was observed for current depression (OR 1.5; 95% CI 0.8-2.7). After removing poor sleep quality from the model, an independent association between current depression (OR 2.6; 95% CI 1.7-3.8) and current anxiety (OR 3.2; 95% CI 1.8-6.0) and GERD was observed, but not for previous depression (OR 1.4; 95% CI 0.7-2.8). CONCLUSION: In this sample of urban-dwelling men, we observed a strong independent association between GERD, anxiety, and current depression, the latter appearing to be partly mediated by poor sleep quality. Patients presenting with GERD should have concurrent mental health assessments in order to identify potential confounders to the successful management of their symptoms.

BIRC3 single nucleotide polymorphism associate with asthma susceptibility and the abundance of eosinophils and neutrophils.

BACKGROUND AND OBJECTIVE: Aberrant apoptosis is a disease susceptibility mechanism relevant for asthma, whereby fragility of the airway epithelium and enhanced survival of inflammatory cells, contributes to its pathogenesis and prolongation. Cellular Inhibitor of Apoptosis Proteins (cIAP) suppress apoptosis, and participate in the immune response. In this study, single nucleotide polymorphisms (SNP) in the BIRC2 (codes cIAP1) and BIRC3 (cIAP2) genes were evaluated for an association with asthma. METHODS: Caucasian asthmatic (n = 203) and control (n = 198) subjects were selected from participants in the North West Adelaide Health Study. SNPs (n = 9) spanning the consecutively positioned BIRC2 and BIRC3 genes, were selected using a haplotype tagging approach. Alleles and haplotype associations were analysed by logistic regression, assuming an additive genetic model, and adjusted for gender and atopy. RESULTS: The frequency of the minor allele for the BIRC3 SNP rs3460 was significantly lower in asthmatics compared to the control cases (P = 0.046). BIRC3 SNPs rs7928663 and rs7127583 associated with a reduction in eosinophil and neutrophil abundance when assessed across the study population (multivariate P values = 0.002, and 0.005, respectively). Further, the frequency of a haplotype tagged by rs3460, rs7928663 and rs7127583 was reduced in the asthma sub group (P = 0.05), while the presence of the major allele for rs7928663 associated with an increased load of circulating eosinophils and neutrophils (multivariate P value = 0.001). CONCLUSIONS: Polymorphisms in the BIRC3 gene, but not BIRC2, are associated with a protective effect with regards to asthma susceptibility, and a reduced load of inflammatory cells.

Designing an evaluation framework for WFME basic standards for medical education.

PURPOSE: To create an evaluation plan for the World Federation for Medical Education (WFME) accreditation standards for basic medical education. METHODS: We conceptualized the 100 basic standards from "Basic Medical Education: WFME Global Standards for Quality Improvement: The 2012 Revision" as medical education program objectives. Standards were simplified into evaluable items, which were then categorized as inputs, processes, outputs and/or outcomes to generate a logic model and corresponding plan for data collection. RESULTS: WFME standards posed significant challenges to evaluation due to complex wording, inconsistent formatting and lack of existing assessment tools. Our resulting logic model contained 244 items. Standard B 5.1.1 separated into 24 items, the most for any single standard. A large proportion of items (40%) required evaluation of more than one input, process, output and/or outcome. Only one standard (B 3.2.2) was interpreted as requiring evaluation of a program outcome. CONCLUSIONS: Current WFME standards are difficult to use for evaluation planning. Our analysis may guide adaptation and revision of standards to make them more evaluable. Our logic model and data collection plan may be useful to medical schools planning an institutional self-review and to accrediting authorities wanting to provide guidance to schools under their purview.

Comparison of anthropometric measures as predictors of cancer incidence: A pooled collaborative analysis of 11 Australian cohorts.

Obesity is a risk factor for cancer. However, it is not known if general adiposity, as measured by body mass index (BMI) or central adiposity [e.g., waist circumference (WC)] have stronger associations with cancer, or which anthropometric measure best predicts cancer risk. We included 79,458 men and women from the Australian and New Zealand Diabetes and Cancer Collaboration with complete data on anthropometry [BMI, WC, Hip Circumference (HC), WHR, waist to height ratio (WtHR), A Body Shape Index (ABSI)], linked to the Australian Cancer Database. Cox proportional hazards models assessed the association between each anthropometric marker, per standard deviation and the risk of overall, colorectal, post-menopausal (PM) breast, prostate and obesity-related cancers. We assessed the discriminative ability of models using Harrell's c-statistic. All anthropometric markers were associated with overall, colorectal and obesity-related cancers. BMI, WC and HC were associated with PM breast cancer and no significant associations were seen for prostate cancer. Strongest associations were observed for WC across all outcomes, excluding PM breast cancer for which HC was strongest. WC had greater discrimination compared to BMI for overall and colorectal cancer in men and women with c-statistics ranging from 0.70 to 0.71. We show all anthropometric measures are associated with the overall, colorectal, PM breast and obesity-related cancer in men and women, but not prostate cancer. WC discriminated marginally better than BMI. However, all anthropometric measures were similarly moderately predictive of cancer risk. We do not recommend one anthropometric marker over another for assessing an individuals' risk of cancer.

Undiagnosed obstructive sleep apnea is independently associated with reductions in quality of life in middle-aged, but not elderly men of a population cohort.

PURPOSE: Obstructive sleep apnea (OSA) is now highly prevalent but largely undiagnosed. Quality of life is an indicator of both the impact of undiagnosed OSA and the need for strategies to increase OSA diagnosis. We determined age-related impacts of undiagnosed OSA on health-related quality of life (HRQL) and whether this was independent of sleepiness and comorbidities. METHODS: In 2010-2012, 837 participants from the Men Androgen Inflammation Lifestyle Environment and Stress Study (population cohort n = 1869, ≥40 years, Adelaide, Australia), without a prior OSA diagnosis underwent full in-home polysomnography (Embletta X100) and completed the Epworth Sleepiness Scale and SF-36 questionnaire. The effects of the apnea-hypopnea index (AHI) on SF-36 physical (PCS) and mental (MCS) component summary scores and standardized SF-36 scale z-scores were estimated using multiple linear regression adjusted for major comorbidities and sleepiness, stratified by age. RESULTS: Men ≤69 years demonstrated significant (p < 0.05) decrements/event increase in AHI in PCS score [unstandardized B coefficient (SE) = -0.068 (0.023)], physical functioning, role physical, general health, and vitality z-scores in fully adjusted models. Severe OSA (AHI ≥30) was associated with significant reductions in PCS [B = -4.1 (1.1)] and MCS score [B = -3.6 (1.2)] independent of sleepiness and comorbidities which were attenuated but persisted in men <69 years without depression. In men aged ≥70 years, statistically significant AHI-associated impairments were generally not seen. CONCLUSIONS: Undiagnosed OSA was a major independent contributor to HRQL impairments in men <69 years. Improved strategies to identify undiagnosed OSA are indicated that may require a reduced focus on daytime sleepiness.

Early clinical exposure through innovative interactive clinical anatomy lectures.

BACKGROUND: Traditional lecture-based teaching of anatomy tends to focus on the discipline per se rather than relating it to clinical conditions. As a result, students often lose interest in the basic sciences. We hypothesized that a lecture format that encourages students to relate anatomy to case presentations might help them in appreciating clinical relevance. We therefore proposed to develop, implement and evaluate innovative interactive clinical anatomy lectures (ICALs) for first year medical students of our institution as a method to implement the 'early clinical exposure' teaching strategy being promoted by the Medical Council of India. METHODS: The first year medical students (n=150) were divided into two groups by lottery: the study group (n=75) and the control group (n=75). The study group received nine ICALs along with traditional gross anatomy lectures (TGL) and dissection. The control group received only TGL along with dissection. A post-test in clinical anatomy was conducted for both groups. The responses of the study group on TGL and ICALs on their learning and understanding of the clinical conditions were collected using the nominal group technique. RESULTS AND CONCLUSION: It is feasible to introduce early clinical exposure within lectures even with 150 students. There was a statistically significant (p<0.001) difference in the mean post-test scores of the two groups, which shows that ICALs are effective in correlating anatomical and clinical information to students. The nominal group technique responses of the study group showed that they appreciated it as a better method of teaching and learning.

Mental health in immigrant men and women in Australia: the North West Adelaide Health Study.

BACKGROUND: There is conflicting evidence of the healthy migrant effect with respect to mental health. This study aims to determine if there are differences in mental health and service use between Australian-born and foreign-born individuals living in South Australia and to consider the differing role of socio-demographic characteristics for Australian-born and foreign-born men and women. METHODS: Data from the North West Adelaide Health study was used to compare foreign-born men and women from English and non-English speaking backgrounds with Australian born men and women on four measures of mental health and service use. A series of logistic regression analyses were conducted. RESULTS: There were no differences between Australian-born and foreign-born individuals from English-speaking backgrounds on any measures. Men from non-English speaking backgrounds had higher odds of depression. Employment and general health were important protectors of mental health for both Australian and foreign-born individuals, while being married was protective for foreign-born men only. Income was generally inversely related to mental health among Australians but the relationship was weaker and less consistent for those born abroad. CONCLUSIONS: Men from non-English speaking backgrounds men may be at increased risk of mental health problems but do not have higher levels of treatment. Help-seeking may need to be encouraged among this group, particularly among unmarried, unemployed men from non-English speaking backgrounds.

Vitamin D levels in an Australian population.

BACKGROUND: Levels of vitamin D in the population have come under increasing scrutiny, however there are only a few studies in Australia which measure levels in the general population. The aim of this study was to measure the levels of vitamin D within a large population cohort and examine the association with seasons and selected demographic and health risk factors. METHODS: A longitudinal cohort study of 2413 participants in the northwest suburbs of Adelaide, South Australia conducted between 2008 and 2010 was used to examine serum levels of 25-hydroxy vitamin D (25(OH)D) in relation to demographic characteristics (age, sex, income, education and country of birth), seasons, the use of vitamin D supplements and selected health risk factors (physical activity, body mass index and smoking). Both unadjusted and adjusted mean levels of serum 25(OH)D were examined, as were the factors associated with the unadjusted and adjusted prevalence of serum 25(OH)D levels below 50 and 75 nmol/L. RESULTS: Overall, the mean level of serum 25(OH)D was 69.2 nmol/L with 22.7% of the population having a serum 25(OH)D level below 50 nmol/L, the level which is generally recognised as vitamin D deficiency. There were significantly higher levels of 25(OH)D among males compared to females (t = 4.65, p < 0.001). Higher levels of 25(OH)D were also measured in summer and autumn compared with winter and spring. Generally, mean levels of 25(OH)D were lower in those classified as obese. Smokers and those undertaking no or less than 150 minutes/week of physical activity also had lower levels of serum vitamin D. Obesity (as classified by body mass index), season and undertaking an insufficient level of physical activity to obtain a health benefit were significantly associated with the prevalence of vitamin D deficiency. CONCLUSIONS: Vitamin D deficiency is prevalent in South Australia, affecting almost one quarter of the population and levels are related to activity, obesity and season even when adjusted for confounding factors. Improved methods of addressing vitamin D levels in population are required.

Zinc-rich inhibitor of apoptosis proteins (IAPs) as regulatory factors in the epithelium of normal and inflamed airways.

Integrity of the airway epithelium (AE) is important in the context of inhaled allergens and noxious substances, particularly during asthma-related airway inflammation where there is increased vulnerability of the AE to cell death. Apoptosis involves a number of signaling pathways which activate procaspases leading to cleavage of critical substrates. Understanding the factors which regulate AE caspases is important for development of strategies to minimize AE damage and airway inflammation, and therefore to better control asthma. One such factor is the essential dietary metal zinc. Zinc deficiency results in enhanced AE apoptosis, and worsened airway inflammation. This has implications for asthma, where abnormalities in zinc homeostasis have been observed. Zinc is thought to suppress the steps involved in caspase-3 activation. One target of zinc is the family of inhibitor of apoptosis proteins (IAPs) which are endogenous regulators of caspases. More studies are needed to identify the roles of IAPs in regulating apoptosis in normal and inflamed airways and to study their interaction with labile zinc ions. This new information will provide a framework for future clinical studies aimed at monitoring and management of airway zinc levels as well as minimising airway damage and inflammation in asthma.

X-linked inhibitor of apoptosis single nucleotide polymorphisms and copy number variation are not risk factors for asthma.

BACKGROUND AND OBJECTIVE: Aberrant apoptosis in asthma contributes to airway inflammation. Early apoptosis and fragility of airway epithelial cells and delayed apoptosis of inflammatory lymphocytes can cooperate to increase airway inflammation. In this study, single nucleotide polymorphisms (SNPs) and copy number variation (CNV) in the Baculoviral inhibitor of apoptosis protein repeat-containing 4 (BIRC4) gene (which encodes X-linked inhibitor of apoptosis protein) were evaluated for associations with asthma. METHODS: Asthma cases (n = 203) were identified from Caucasian cohort participants in the North West Adelaide Health Study and matched with 198 controls. Asthma status was defined using self-report of doctor-diagnosed asthma, in conjunction with spirometry and bronchodilator response. Seven SNPs, which spanned the entire BIRC4 gene, were selected for the study on the basis of a haplotype tagging approach. SNPs genotyping was performed on the SEQUENOM MassARRAY iPLEX Gold platform, and genotyping success rate was > 98%. BIRC4 gene CNV was measured using a duplex Taqman qPCR assay, with RNAseP as the reference gene. Alleles and haplotype associations were analysed by logistic regression, assuming an additive genetic model, and adjusted for gender and atopy. RESULTS: BIRC4 gene copy number was determined entirely by gender. All SNPs were in Hardy-Weinberg equilibrium for both case and control females. BIRC4 allele and haplotype frequencies were comparable between asthma cases and controls. CONCLUSIONS: There is no evidence of CNV in BIRC4, and BIRC4 is not a susceptibility gene for asthma.

Competency-based training: who benefits?

Competency based training describes progression through training referenced to the demonstrated ability to perform certain tasks. In recent years, this has become the dominant curriculum model. We seek to examine who benefits from a competency based approach to medical education. For the regulators and service, the apparent advantage is in terms of apparent measurable accountability and flexibility. For assessors, the promise of competence based assessments in the workplace to provide a reliable and objective measurement of a trainee's performance has not been demonstrated in practice. For the doctor in training, there is very little evidence to show benefit from competency based training. Competency based training places emphasis on individual skills rather than overall learning experience thus risks diminishing the role of the trainee in the workplace. Any form of medical education that devalues workplace based learning will ultimately harm the profession and, in turn, patient care.

Abdominal adiposity and obstructive airway disease: testing insulin resistance and sleep disordered breathing mechanisms.

BACKGROUND: This study examined associations of abdominal adiposity with lung function, asthma symptoms and current doctor-diagnosed asthma and mediation by insulin resistance (IR) and sleep disordered breathing (SDB). METHODS: A random sample of 2500 households was drawn from the community of Whyalla, South Australia (The Whyalla Intergenerational Study of Health, WISH February 2008 - July 2009). Seven-hundred twenty-two randomly selected adults (≥18 years) completed clinical protocols (32.2% response rate). Lung function was measured by spirometry. Post-bronchodilator FEV1/FVC was used to measure airway obstruction and reversibility of FEV1 was calculated. Current asthma was defined by self-reported doctor-diagnosis and evidence of currently active asthma. Symptom scores for asthma (CASS) and SDB were calculated. Intra-abdominal fat (IAF) was estimated using dual-energy x-ray absorptiometry (DXA). IR was calculated from fasting glucose and insulin concentrations. RESULTS: The prevalence of current doctor-diagnosed asthma was 19.9% (95% CI 16.7 - 23.5%). The ratio of observed to expected cases given the age and sex distribution of the population was 2.4 (95%CI 2.1, 2.9). IAF was not associated with current doctor-diagnosed asthma, FEV1/FVC or FEV1 reversibility in men or women but was positively associated with CASS independent of IR and SDB in women. A 1% increase in IAF was associated with decreases of 12 mL and 20 mL in FEV1 and FVC respectively in men, and 4 mL and 7 mL respectively in women. SDB mediated 12% and 26% of these associations respectively in men but had minimal effects in women. CONCLUSIONS: In this population with an excess of doctor-diagnosed asthma, IAF was not a major factor in airway obstruction or doctor-diagnosed asthma, although women with higher IAF perceived more severe asthma symptoms which did not correlate with lower FEV1. Higher IAF was significantly associated with lower FEV1 and FVC and in men SDB mechanisms may contribute up to one quarter of this association.

The challenge of integrating new online education packages into existing curricula: a new model.

BACKGROUND: In 2009, The National Institute for Health and Clinical Excellence (NICE) developed an undergraduate online learning package on the practical application of evidence-based medicine with the intention that it would be integrated into existing medical curricula. METHODS: Complementary methodologies were used to yield a diversity of quantitative and qualitative data on how the online learning package was integrated. RESULTS: The modules of the online learning package received an overall positive reaction from the users but uptake of the modules was lower than expected. Even though some curriculum integration occurred, several students were unaware that the package existed, some lacked the time to use the package and others would have preferred to have had the package earlier in their course. CONCLUSIONS: A new model for the effective integration of online education packages into existing undergraduate medical curricula is proposed, especially when developed by external organisations. This new model should enable educationalists to better reveal and overcome the contextual and process challenges, barriers and solutions to implementing effective flexible learning approaches. When introducing new learning resources into a curriculum, many factors are important, especially the learners' perceived needs and how these vary at different stages of their course.