Remote primary care during the COVID-19 pandemic for people experiencing homelessness: a qualitative study.

BACKGROUND: The COVID-19 pandemic has caused unprecedented disruption and change to the organisation of primary care, including for people experiencing homelessness who may not have access to a phone. Little is known about whether the recent changes required to deliver services to people experiencing homelessness will help to address or compound inequality in accessing care. AIM: To explore the experience and impact of organisational and technology changes in response to COVID-19 on access to health care for people experiencing homelessness. DESIGN AND SETTING: An action-led and participatory research methodology was employed in three case study sites made up of primary care services delivering care for people experiencing homelessness. METHOD: Individual semi-structured interviews were conducted with 21 people experiencing homelessness and 22 clinicians and support workers. Interviews were analysed using a framework approach. RESULTS: The move to remote telephone consultations highlighted the difficulties experienced by participants in accessing health care. These barriers included problems at the practice level associated with remote triage as participants did not always have access to a phone or the means to pay for a phone call. This fostered increased reliance on support workers and clinicians working in the community to provide or facilitate a primary care appointment. CONCLUSION: The findings have emphasised the importance of addressing practical and technology barriers as well as supporting communication and choice for mode of consultation. The authors argue that consultations should not be remote 'by default' and instead take into consideration both the clinical and social factors underpinning health.

How clinical communication has become a core part of medical education in the UK.

CONTEXT: This paper sets out to analyse and interpret the complex events of the last 20 years in order to understand how the teaching and learning of clinical communication has emerged as a core part of the modern undergraduate medical curriculum in most medical schools in the UK. METHODS: The paper analyses the effects of key political, sociological, historical and policy influences on clinical communication development. RESULTS: Political influences include: the effects of neo-liberalism on society and on the professions in general; the challenging of traditional notions of professionalism in medicine; the creation of an internal market within the National Health Service, and the disempowerment of the medical lobby. Sociological influences include: the effects of a 'marketised' society on medicine and subtle shifts in the doctor-patient relationship because of this; the emergence of globalised information through the Internet, and the influence of increased litigation against doctors. Historical influences include: the effects of a change in emphasis for medical education away from an inflated factual curriculum towards a curriculum that recognises the importance of student attitudes and the teaching and learning of clinical communication skills. Policy influences include the important effects of Tomorrow's Doctors and the Dearing Report on the modern medical curriculum. CONCLUSIONS: The paper concludes with a developmental map that charts the complex influences on clinical communication teaching and learning and a brief commentary on the growing body of teachers who deliver and develop the subject today.

Effect of ambulatory oxygen on quality of life for patients with fibrotic lung disease (AmbOx): a prospective, open-label, mixed-method, crossover randomised controlled trial.

BACKGROUND: In fibrotic interstitial lung diseases, exertional breathlessness is strongly linked to health-related quality of life (HRQOL). Breathlessness is often associated with oxygen desaturation, but few data about the use of ambulatory oxygen in patients with fibrotic interstitial lung disease are available. We aimed to assess the effects of ambulatory oxygen on HRQOL in patients with interstitial lung disease with isolated exertional hypoxia. METHODS: AmbOx was a prospective, open-label, mixed-method, crossover randomised controlled clinical trial done at three centres for interstitial lung disease in the UK. Eligible patients were aged 18 years or older, had fibrotic interstitial lung disease, were not hypoxic at rest but had a fall in transcutaneous arterial oxygen saturation to 88% or less on a screening visit 6-min walk test (6MWT), and had self-reported stable respiratory symptoms in the previous 2 weeks. Participants were randomly assigned (1:1) to either oxygen treatment or no oxygen treatment for 2 weeks, followed by crossover for another 2 weeks. Randomisation was by a computer-generated sequence of treatments randomly permuted in blocks of constant size (fixed size of ten). The primary outcome, which was assessed by intention to treat, was the change in total score on the King's Brief Interstitial Lung Disease questionnaire (K-BILD) after 2 weeks on oxygen compared with 2 weeks of no treatment. General linear models with treatment sequence as a fixed effect were used for analysis. Patient views were explored through semi-structured topic-guided interviews in a subgroup of participants. This study was registered with ClinicalTrials.gov, number NCT02286063, and is closed to new participants with all follow-up completed. FINDINGS: Between Sept 10, 2014, and Oct 5, 2016, 84 patients were randomly assigned, 41 randomised to ambulatory oxygen first and 43 to no oxygen. 76 participants completed the trial. Compared with no oxygen, ambulatory oxygen was associated with significant improvements in total K-BILD scores (mean 55·5 [SD 13·8] on oxygen vs 51·8 [13·6] on no oxygen, mean difference adjusted for order of treatment 3·7 [95% CI 1·8 to 5·6]; p<0·0001), and scores in breathlessness and activity (mean difference 8·6 [95% CI 4·7 to 12·5]; p<0·0001) and chest symptoms (7·6 [1·9 to 13·2]; p=0·009) subdomains. However, the effect on the psychological subdomain was not significant (2·4 [-0·6 to 5·5]; p=0·12). The most common adverse events were upper respiratory tract infections (three in the oxygen group and one in the no-treatment group). Five serious adverse events, including two deaths (one in each group) occurred, but none were considered to be related to treatment. INTERPRETATION: Ambulatory oxygen seemed to be associated with improved HRQOL in patients with interstitial lung disease with isolated exertional hypoxia and could be an effective intervention in this patient group, who have few therapeutic options. However, further studies are needed to confirm this finding. FUNDING: UK National Institute for Health Research.

Exploring the use of student-led simulated practice learning in pre-registration nursing programmes.

Simulated practice learning is used in pre-registration nursing programmes to replicate situations that nursing students are likely to encounter in clinical practice, but in a safe and protected academic environment. However, lecturer-led simulated practice learning has been perceived as detached from contemporary nursing practice by some nursing students. Therefore, a pilot project was implemented in the authors' university to explore the use of student-led simulated practice learning and its potential benefits for nursing students. AIM: To evaluate the effectiveness of student-led simulated practice learning in pre-registration nursing programmes. The authors specifically wanted to: enhance the students' skills; improve their critical thinking and reflective strategies; and develop their leadership and management techniques. METHOD: A literature review was undertaken to examine the evidence supporting student-led simulated practice learning. A skills gap analysis was then conducted with 35 third-year nursing students to identify their learning needs, from which suitable simulated practice learning scenarios and sessions were developed and undertaken. These sessions were evaluated using debriefs following each of the sessions, as well as informal discussions with the nursing students. FINDINGS: The pilot project identified that student-led simulated learning: developed nursing students' ability to plan and facilitate colleagues' practice learning; enabled nursing students to develop their mentoring skills; reinforced the nursing students' self-awareness, which contributed to their personal development; and demonstrated the importance of peer feedback and support through the debriefs. Challenges included overcoming some students' resistance to the project and that some lecturers were initially concerned that nursing students may not have the clinical expertise to lead the simulated practice learning sessions effectively. CONCLUSION: This pilot project has demonstrated how student-led simulated practice learning sessions could be used to engage nursing students as partners in their learning, enhance their knowledge and skills, and promote self-directed learning.

Learning and teaching clinical communication in the clinical workplace.

BACKGROUND: Clinical communication teaching and learning has become increasingly separate from the clinical workplace over the last 20 years in the UK, and in many medical schools is front-loaded to the early years of the curriculum. Many reasons exist to explain this separation, including the increasing use of simulation. However, learning by simulation alone is not ideal, and the literature now points towards a new direction that blends simulation with authentic experiences in the clinical workplace to aid the transition to clinical life. CONTEXT: This article presents a practical example of collaboration between a London medical school and a hospital trust to provide an integrated clinical communication learning experience for students by situating teaching on the clinical wards for senior medical students. Clinical communication teaching and learning has become increasingly separate from the clinical workplace INNOVATION: We outline a new teaching initiative, the 'Communication on the wards' pilot project, that blends clinical communication teaching with ward-based learning in an authentic environment, with patients, medical students and teachers working together. IMPLICATIONS: This teaching initiative was a practical attempt to bridge the theory-practice gap in clinical communication education, and to place learning in the clinical workplace for students. As such, it was enjoyed by all those who took part, and may be the way forward for clinical communication teaching and learning in the future.

Clinical Assessment of Scapula Motion: Scapula Upward Rotation and Relationship with Injury in Swimmers.

Abnormal scapulothoracic mechanics and scapulohumeral rhythm are implicated in shoulder pathologies, including glenohumeral impingement and rotator cuff tears. Upward scapula rotation, specifically asymmetry of scapula motion and associations of patterns through range with injury, was investigated in dominant and non-dominant limbs of nationally ranked junior and Paralympic swimmers during competition season. The static and throughout phases measures of upward scapula rotation were: Phase I (start position, 45°), Phase II (45° to 90°), Phase III (90° to 135°) and Phase IV (135° to max). Injury was assessed with a validated questionnaire. Differences between side (dominant and non-dominant), group (junior and Paralympic), and phase were examined. Significant differences (P < 0.05) between groups were identified for dominant side at rest, 45° and 135°, and in phases II and IV (including range). Scapulohumeral rhythm was higher in the non-dominant limb of Paralympic swimmers but in the dominant limb of junior swimmers. Greatest differences in upward rotation between injured and non-injured swimmers were found in Phase 1: 43.6% (3.3°) Paralympic; 73.1% (8°) junior. Results suggest asymmetry of movement in both limbs, through all phases, and at single points in range, should be investigated for assessing injury and developing preventive strategies and rehabilitation protocols.

Carers: The navigators of the maze of care for people with dementia-A qualitative study.

BACKGROUND: Dementia is a challenge in our society, with individuals accessing services across multiple settings. Carers are navigating and delivering care services in the home. This research sought to investigate the experiences of people with dementia and their carers when transitioning home from hospital. METHODS: This study used a qualitative descriptive design, employing in-depth interviews with 30 carers recruited through networks known to one state branch of Alzheimer's Australia. Emerging themes were validated in one focus group. RESULTS: During the hospital stay carers experienced a paradox: being required to deliver care yet perceiving that they were being ignored in regard to decisions about care. The time in hospital was considered by some carers to be stressful, as they were concerned about the safety of the person with dementia. Many reported that discharge home was rarely planned and coordinated. Returning home carers found re-establishing and/or accessing new services challenging, with available services often inappropriate to need. CONCLUSION: The paradox of the care experience in the acute setting, whereby the carer was either invited, or sought, to deliver care, yet was excluded in staff decisions about that care, challenges the current communication and coordination of care. For people with dementia and their carers, there is a need for a coordinated seamless service that enables continued unbroken care and support from acute care to home. Carers also need support navigating the wide range of services available and importantly both carers and care providers may need to understand service boundaries. RECOMMENDATIONS: This study highlights the need to acknowledge the expertise of the carer, and their need for support. Enabling a smooth discharge from hospital and support to navigate care access in the community is paramount. These experiences provide insight into gaps in service provision and modifying existing services may lead to improved experiences.

Perspective: clinical communication education in the United Kingdom: some fresh insights.

Clinical communication education is now part of the core curriculum of every medical school in the United Kingdom and the United States. It has emerged over 30 years because of various societal, political, and policy drivers and is supported by an impressive evidence base.For a variety of reasons, however, clinical communication has become separated from other parts of medical education and tends to be positioned in the early years of the curriculum, when students have limited experience of being in the clinical workplace and working with patients. The teachers of clinical communication, whether medical-school-based or clinically based, may not share learning goals for the subject and this may, therefore, provide a disintegrated learning experience for students.Clinical communication teachers need to inject fresh thinking into the teaching and learning of the subject to unite it with clinical practice in the authentic clinical workplace. Engaging with theories of workplace learning, which aim to overcome the theory/practice gap in vocational education, may be the way forward. The author suggests various ways that this might be achieved-for example, by situating clinical communication education throughout the whole undergraduate curriculum, by integrating the topic of clinical communication with other areas of medical education, by developing coteaching and curriculum design partnerships between medical school and clinical workplace, and by developing a greater range of postgraduate education that offers opportunities for professional development in clinical communication for qualified doctors that is complementary with what is taught in undergraduate education.

Transferring clinical communication skills from the classroom to the clinical environment: perceptions of a group of medical students in the United kingdom.

PURPOSE: To better understand the transfer of classroom-learned clinical communication skills (CCS) to the clinical environment of the hospital ward, where they are practiced and refined by students. METHOD: The author first briefly presents the literature on clinical communication, provides an overview of the debates around the notion of transfer, and presents a sociocultural model of developmental transfer applied to CCS learning. Second, she describes a focus group and nine individual interviews carried out with 17 fourth-year medical students at one medical school in the United Kingdom in 2008. The goal was to elicit their views of CCS teaching, learning, and transfer of CCS to the clinical workplace. RESULTS: The findings are presented under the four main themes of transition, where students experienced the transition from the medical school to the hospital ward as a mixture of positive and negative impacts on transferring their CCS skills; the clinical culture, where senior doctors had the greatest impact on student learning and emergent clinical practice; clinical communication as a vehicle for professionalism and being a "good" doctor; and, finally, transfer mechanisms, where simulated practice with actors and the clinical history template were powerful learning tools. CONCLUSIONS: Findings indicate that more needs to be done to support, develop, and embed CCS into the professional practice of medical students in the clinical workplace. This may be achieved by greater collaboration of educators in the academic and clinical environments. Using the developmental transfer model applied to CCS learning may help foster this relationship.

Applying your clinical skills to students and trainees in academic difficulty.

BACKGROUND: When students and trainees in difficulty present late, there are often signs in their history that suggest that earlier identification and intervention might have been possible. Clinical supervisors may have been reluctant to explore issues with them, perhaps because they felt that it was not their role to do so, or that they may not have the necessary skills or perhaps because of the concern of 'opening a can of worms' that they would not be able to address. INNOVATION: In this article we discuss the importance of early identification and intervention, and draw parallels between the skills required to manage students and trainees in difficulty, and those used daily in identifying and exploring issues with patients. This is based on a combined experience of over 30 years in helping students and trainees in difficulty, and in training and mentoring others to do so. Following this medical model, we highlight straightforward methods for: identifying those in difficulty; making a 'diagnosis'; providing simple interventions; and knowing when and how to refer on. We discuss issues around record keeping, confidentiality and ongoing management, with particular reference to the aspects of the doctor-patient interaction that do not transfer to the supervisor-trainee relationship.

The radiological investigation of subarachnoid haemorrhage.

Subarachnoid haemorrhage is an important condition with a high mortality, so prompt diagnosis is essential. This article will review the investigation of subarachnoid haemorrhage with a radiological bias. Appropriate clinical correlation will be included and it will look at some of the more interesting areas in the investigation of this condition.

Outcome at 7 years of children diagnosed with autism at age 2: predictive validity of assessments conducted at 2 and 3 years of age and pattern of symptom change over time.

OBJECTIVE: To examine the predictive validity of symptom severity, cognitive and language measures taken at ages 2 and 3 years to outcome at age 7 in a sample of children diagnosed with autism at age 2. METHOD: Twenty-six children diagnosed with autism at age 2 were re-assessed at ages 3 and 7 years. At each age symptom severity, cognitive and language assessments were completed. RESULTS: The pattern of autistic symptom severity varied over time by domain. Across time, children moved across diagnostic boundaries both in terms of clinical diagnosis and in terms of instrument diagnosis on the Autism Diagnostic Interview-Revised (ADI-R). On all measures group variability in scores increased with age. Although non-verbal IQ (NVIQ) for the group as a whole was stable across the 3 assessments, this masked considerable individual instability. Standard assessments at age 2 did not predict outcome at age 7 even within the same domain of functioning. In contrast, standard assessments at age 3 did predict outcome. However, a measure of rate of non-verbal communicative acts taken from an interactive play-based assessment at age 2 was significantly associated with language, communication and social outcomes at age 7. CONCLUSIONS: The trajectory of autism symptoms over time differed in different domains, suggesting that they may be, at least in part, separable. Variability in language, NVIQ and symptom severity increased over time. Caution is required when interpreting the findings from assessments of children with autism at age 2 years. At this age measures of rate of non-verbal communication might be more informative than scores on standard psychometric tests. Predictive validity of assessments at age 3 years was greater.