Improving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon - a qualitative study exploring the experiences and perceptions of patients and healthcare professionals.

BACKGROUND: Management for multi-drug-resistant tuberculosis (MDR-TB) is challenging and has poor patient outcomes. Peru has a high burden of MDR-TB. The Loreto region in the Peruvian Amazon is worst affected for reasons including high rates of poverty and poor healthcare access. Current evidence identifies factors that influence MDR-TB medication adherence, but there is limited understanding of the patient and healthcare professional (HCP) perspective, the HCP-patient relationship and other factors that influence outcomes. A qualitative investigation was conducted to explore and compare the experiences and perceptions of MDR-TB patients and their dedicated HCPs to inform future management strategies. METHOD: Twenty-six, semi-structured in-depth interviews were conducted with 15 MDR-TB patients and 11 HCPs who were purposively recruited from 4 of the worst affected districts of Iquitos (capital of the Loreto region). Field notes and transcripts of the two groups were analysed separately using thematic content analysis. Ethics approval was received from the Institutional Research Ethics Committee, Department of Health, Loreto, and the University of Birmingham Internal Research Ethics Committee. RESULTS: Four key themes influencing patient outcomes emerged in each participant group: personal patient factors, external factors, clinical factors, and the HCP-patient relationship. Personal factors included high standard patient and population knowledge and education, which can facilitate engagement with treatment by encouraging belief in evidence-based medicine, dispelling belief in natural medicines, health myths and stigma. External factors included the adverse effect of the financial impact of MDR-TB on patients and their families. An open, trusting and strong HCP-patient relationship emerged as a vitally important clinical factor influencing of patient outcomes. The results also provide valuable insight into the dynamic of the relationship and ways in which a good relationship can be fostered. CONCLUSIONS: This study highlights the importance of financial support for patients, effective MDR-TB education and the role of the HCP-patient relationship. These findings add to the existing evidence base and provide insight into care improvements and policy changes that could improve outcomes if prioritised by local and national government.

Understanding professional development: Case studies of remedial support.

This study reports on work undertaken by the Interactive Studies Unit (ISU), University of Birmingham. A total of 727 doctors were referred to the ISU for one-to-one remedial support in a variety of non-clinical areas between 2010 and 2018. The close-in scrutiny which one-to-one support offers provides an opportunity to study and reflect on such issues as values and professionalism, which are notoriously difficult to define or reach objective judgments about. There are fundamental difficulties, in particular, in inferring underlying values from an individual's behavior. The basic taxonomy of referrals the ISU works with, and which echoes those developed elsewhere, considers problems as being at the level of the self, interactions with others, or working in an institutional or societal context. Six common generic problems are identified, and presented and discussed as generic cases. These are designed to be representative of the complex manner in which behavior and values interact, and problems at the three levels above impinge on each other. All cases are accompanied by details of suggested educational activities.

Using standardized patients to assess communication skills in medical and nursing students.

BACKGROUND: A number of recent developments in medical and nursing education have highlighted the importance of communication and consultation skills (CCS). Although such skills are taught in all medical and nursing undergraduate curriculums, there is no comprehensive screening or assessment programme of CCS using professionally trained Standardized Patients Educators (SPE's) in Ireland. This study was designed to test the content, process and acceptability of a screening programme in CCS with Irish medical and nursing students using trained SPE's and a previously validated global rating scale for CCS. METHODS: Eight tutors from the Schools of Nursing and Medicine at University College Cork were trained in the use of a validated communication skills and attitudes holistic assessment tool. A total of forty six medical students (Year 2 of 5) and sixty four nursing students (Year 2/3 of 4) were selected to under go individual CCS assessment by the tutors via an SPE led scenario. Immediate formative feedback was provided by the SPE's for the students. Students who did not pass the assessment were referred for remediation CCS learning. RESULTS: Almost three quarters of medical students (33/46; 72%) and 81% of nursing students (56/64) passed the CCS assessment in both communication and attitudes categories. All nursing students had English as their first language. Nine of thirteen medical students referred for enhanced learning in CCS did not have English as their first language. CONCLUSIONS: A significant proportion of both medical and nursing students required referral for enhanced training in CCS. Medical students requiring enhanced training were more likely not to have English as a first language.

Gender as a variable in the assessment of final year degree-level communication skills.

AIM: To investigate possible bias due to gender combination of students, role players and examiners in a high-stakes assessment. SETTING: Valid oral interactive contextualized examinations (VOICEs) is a long-station OSCE-style exam in general practice (GP). At the time of writing it consisted of 65% of the student's final GP mark. METHOD: In the VOICE, students undertake six tasks--four vivas and two role-plays. "Patient" roles are taken by professional role players who work regularly on the undergraduate curriculum. During the role-play, the student's clinical competence is assessed by an observing GP examiner. The communication skills marks are awarded by the role player and the examiner together, by negotiation. Data have been recorded detailing the role player's initial marks, the examiner's initial marks and their final (awarded) agreed marks for 1024 consultations. SAMPLE: 512 final year medical students, 28 role players and 48 examiners. There were no inclusion or exclusion criteria. All those present on exam day became part of the data. RESULTS: There was a significant relationship between gender and performance for some, but not all, stations. Correlations for multiple comparisons removed the significance. Female students perform better across the board than male students. While not always significant, this did affect grading. There was no significant association between the genders of role players and examiners with the question choices. There has been a significant worsening of male results since 1999. Differences exist in the way that pairs of mixed or single genders score students.

Hitting the mark: negotiated marking and performance factors in the communication skills element of the VOICE examination.

INTRODUCTION: Communication skills assessment is complex. Standardised patient use is widespread, but anxiety exists around the use of role players as assessors of competence in high stakes examinations. This study measures the level of agreement between scoring examiners and role players, and considers their influence on each other. Examiner status and question choices are analysed as variables. METHOD: The valid oral interactive contextualised examination (VOICE) is a general practice examination styled as an objective structured clinical examination (OSCE) of six 15-minute stations, which include two role-played consultations with professional role players. The examination candidates are final year medical students. Clinical components are examined by a general practitioner (GP). Communication skills are assessed by these examiners in conjunction with the role players, through a process of negotiation. Descriptive professionalism/attitude bandings are used as percentage-scoring guidelines. Checklists are not used. For this study, the initial (independently) perceived marks of the two scoring groups and their agreed final (awarded) marks were recorded, along with other variables including gender, performance factors, demographics and the nature of the question. Data represents 512 students undertaking 1024 simulated consultations, examined by 28 role players and 46 examiners. Analysis was carried out using SPSS Version 10. RESULTS: Results show that the examination and negotiation process is consistent. Role players have a direct influence on scoring. The examiner's background is a significant variable [F9,1014 = 4.207, P < 0.001]. Students perform less well on questions involving higher degrees of clinical information giving. Question choice is not significant [F30,3039 = 1.397, P=0.074]. DISCUSSION: The variables in the examination do not indicate any discrepancy substantial enough to bias a student's grade. Negotiated marking in this context is considered safe and reliable.

Simulated patients in the community pharmacy setting. Using simulated patients to measure practice in the community pharmacy setting.

BACKGROUND: Performance measurement and quality of care in community pharmacy settings is problematic because of the lack of formal patient registration and the resultant risk of selection bias. Although simulated patients have been used for teaching and education purposes, particularly in medical settings, their use as a research tool requires exploration in other health settings. The purpose of this paper is to describe how we used simulated patients to measure professional performance of community pharmacy staff. METHOD: Sixty pharmacies participated in a randomised controlled trial (RCT) to evaluate the effectiveness and efficiency of two guideline implementation strategies in the community pharmacy setting. The primary outcome measure for the study was derived from assessment forms completed by simulated patients following covert visits to participating pharmacies. RESULTS: Of the 420 simulated patient visits scheduled, 384 (91%) were completed. Nine visits were reported by pharmacy staff using reply-paid postcards, four of which concurred with known SP visits. Each detected visit was made by a different SP. In a post-intervention survey, 26 (52%) pharmacists stated they had been apprehensive about the use of simulated patients as part of the study, however, 41 (82%) pharmacists agreed that SP visits were an acceptable research method to use in a community pharmacy setting. DISCUSSION: Simulated patients are a feasible method of assessing professional performance in community pharmacy settings and overcome the methodological problems of other measurement methods. Further research is needed to assess the reliability and validity of simulated patients.