COVID-19 fosters social accountability in medical education.

The COVID-19 pandemic has highlighted embedded inequities and fragmentation in our health systems. Traditionally, structural issues with health professional education perpetuate these. COVID-19 has highlighted inequities, but may also be a disruptor, allowing positive responses and system redesign. Examples from health professional schools in high and low- and middle-income countries illustrate pro-equity interventions of current relevance. We recommend that health professional schools and planners consider educational redesign to produce a health workforce well equipped to respond to pandemics and meet future need.

Addressing the health advocate role in medical education.

The health advocate role is an essential and underappreciated component of the CanMEDs competency framework. It is tied to the concept of social accountability and its application to medical schools for preparing future physicians who will work to ensure an equitable healthcare system. Student involvement in health advocacy throughout medical school can inspire a long-term commitment to address health disparities. The Social Medicine Network (SMN) provides an online platform for medical trainees to seek opportunities to address health disparities, with the goal of bridging the gap between the social determinants of health and clinical medicine. This online platform provides a list of health advocacy related opportunities for addressing issues that impede health equity, whether through research, community engagement, or clinical care.First implemented at the University of British Columbia, the SMN has since expanded to other medical schools across Canada. At the University of Ottawa, the SMN is being used to augment didactic teachings of health advocacy and social accountability. This article reports on the development and application of the SMN as a resource for medical trainees seeking meaningful and actionable opportunities to enact their role as health advocates.

Community perceptions of pre-eclampsia in rural Karnataka State, India: a qualitative study.

BACKGROUND: Maternal deaths have been attributed in large part to delays in recognition of illness, timely transport to facility, and timely treatment once there. As community perceptions of pregnancy and their complications are critical to averting maternal morbidity and mortality, this study sought to contribute to the literature and explore community-based understandings of pre-eclampsia and eclampsia. METHODS: The study was conducted in rural Karnataka State, India, in 2012-2013. Fourteen focus groups were held with the following community stakeholders: three with community leaders (n = 27), two with male decision-makers (n = 19), three with female decision-makers (n = 41), and six with reproductive age women (n = 132). Focus groups were facilitated by local researchers with clinical and research expertise. Discussions were audio-recorded, transcribed verbatim and translated to English for thematic analysis using NVivo 10. RESULTS: Terminology exists in the local language (Kannada) to describe convulsions and hypertension, but there were no terms that are specific to pregnancy. Community participants perceived stress, tension and poor diet to be precipitants of hypertension in pregnancy. Seizures in pregnancy were thought to be brought on by anaemia, poor medical adherence, lack of tetanus toxoid immunization, and exposure in pregnancy to fire or water. Sweating, fatigue, dizziness-unsteadiness, swelling, and irritability were perceived to be signs of hypertension, which was recognized to have the potential to lead to eclampsia or death. Home remedies, such as providing the smell of onion, placing an iron object in the hands, or squeezing the fingers and toes, were all used regularly to treat seizures prior to accessing facility-based care although transport is not delayed. CONCLUSIONS: It is evident that 'pre-eclampsia' and 'eclampsia' are not well-known; instead hypertension and seizures are perceived as conditions that may occur during or outside pregnancy. Improving community knowledge about, and modifying attitudes towards, hypertension in pregnancy and its complications (including eclampsia) has the potential to address community-based delays in disease recognition and delays in treatment that contribute to maternal and perinatal morbidity and mortality. Advocacy and educational initiatives should be designed to target knowledge gaps and potentially harmful practices, and respond to cultural understandings of disease. TRIAL REGISTRATION: NCT01911494.

Utilization of maternal health care services and their determinants in Karnataka State, India.

BACKGROUND: Karnataka State continues to have the highest rates of maternal mortality in south India at 144/100,000 live births, but lower than the national estimates of 190-220/100,000 live births. Various barriers exist to timely and appropriate utilization of services during pregnancy, childbirth and postpartum. This study aimed to describe the patterns and determinants of routine and emergency maternal health care utilization in rural Karnataka State, India. METHODS: This study was conducted in Karnataka in 2012-2013. Purposive sampling was used to convene twenty three focus groups and twelve individual interviews with community and health system representatives: Auxiliary Nurse Midwives and Staff Nurses, Accredited Social Health Activists, community leaders, male decision-makers, female decision-makers, women of reproductive age, medical officers, private health care providers, senior health administrators, District health officers, and obstetricians. Local researchers familiar with the setting and language conducted all focus groups and interviews, these researchers were not known to community participants. All discussions were audio recorded, transcribed, and translated to English for analysis. A thematic analysis approach was taken utilizing an a priori thematic framework as well as inductive identification of themes. RESULTS: Most women in the focus groups reported regular antenatal care attendance, for an average of four visits, and more often for high-risk pregnancies. Antenatal care was typically delivered at the periphery by non-specialised providers. Participants reported that sought was care women experienced danger signs of complications. Postpartum care was reportedly rare, and mainly sought for the purpose of neonatal care. Factors that influenced women's care-seeking included their limited autonomy, poor access to and funding for transport for non-emergent conditions, perceived poor quality of health care facilities, and the costs of care. CONCLUSIONS: Rural south Indian communities reported regular use of health care services during pregnancy and for delivery. Uptake of maternity care services was attributed to new government programmes and increased availability of maternity services; nevertheless, some women delayed disclosure of pregnancy and first antenatal visit. Community-based initiatives should be enhanced to encourage early disclosure of pregnancies and to provide the community information regarding the importance of facility-based care. Health facility infrastructure in rural Karnataka should also be enhanced to ensure a consistent power supply and improved cleanliness on the wards. TRIAL REGISTRATION: NCT01911494.

International fieldwork placements in low-income countries: Exploring community perspectives.

BACKGROUND: There has been a significant increase in the number of occupational and physical therapy students going on international fieldwork placements in low-income countries. Yet, there has been a lack of research describing this experience from the agencies that host students. The research question was 'how do members of an agency within a low-income country perceive, interpret and give meaning to international fieldwork placements where students from a Canadian university provide occupational and physical therapy services?' METHODS: Purposive sampling was used to recruit participants from five affiliated international fieldwork sites. Six semi-structured interviews exploring the perspectives of individuals from agency sites in low-income countries facilitated the data collection. Interviews were audiotaped and transcribed verbatim for thematic analysis. RESULTS: Four themes provided insight into the participants' experience of hosting student therapists. Participants emphasised: (i) there was a reciprocity of learning between agency members and students; (ii) they felt responsible for the health and safety of the students, as well as providing an enriching experience; (iii) participants questioned the preparation phase; and (iv) recommendations were made by participants to strengthen partnerships while contemplating sustainable practices. CONCLUSIONS: This study highlighted that effective preparation, enhanced communication, reflection and reciprocity is necessary to achieve what hosting agencies view as sustainable international placements. These results provide a platform for stakeholders to question their current processes for fieldwork placement engagement and potential suggestions for improving current international fieldwork partnerships.

"You don't want to lose that trust that you've built with this patient...": (dis)trust, medical tourism, and the Canadian family physician-patient relationship.

BACKGROUND: Recent trends document growth in medical tourism, the private pursuit of medical interventions abroad. Medical tourism introduces challenges to decision-making that impact and are impacted by the physician-patient trust relationship-a relationship on which the foundation of beneficent health care lies. The objective of the study is to examine the views of Canadian family physicians about the roles that trust plays in decision-making about medical tourism, and the impact of medical tourism on the therapeutic relationship. METHODS: We conducted six focus groups with 22 family physicians in the Canadian province of British Columbia. Data were analyzed thematically using deductive and inductive codes that captured key concepts across the narratives of participants. RESULTS: Family physicians indicated that they trust their patients to act as the lead decision-makers about medical tourism, but are conflicted when the information they are managing contradicts the best interests of the patients. They reported that patients distrust local health care systems when they experience insufficiencies in access to care and that this can prompt patients to consider going abroad for care. Trust fractures in the physician-patient relationship can arise from shame, fear and secrecy about medical tourism. CONCLUSIONS: Family physicians face diverse tensions about medical tourism as they must balance their roles in: (1) providing information about medical tourism within a context of information deficits; (2) supporting decision-making while distancing themselves from patients' decisions to engage in medical tourism; and (3) acting both as agents of the patient and of the domestic health care system. These tensions highlight the ongoing need for reliable third-party informational resources about medical tourism and the development of responsive policy.

Systematic reviews in medical education: a practical approach: AMEE guide 94.

The twentieth century saw a paradigm shift in medical education, with acceptance that 'knowledge' and 'truth' are contextual, in flux and always evolving. The twenty-first century has seen a greater explosion in computer technology leading to a massive increase in information and an ease of availability, both offering great potential to future research. However, for many decades, there have been voices within the health care system raising an alarm at the lack of evidence to support widespread clinical practice; from these voices, the concept of and need for evidence-based health-care has grown. Parallel to this development has been the emergence of evidence-based medical education; if healthcare is evidence-based, then the training of practitioners who provide this healthcare must equally be evidence-based. Evidence-based medical education involves the systematic collection, synthesis and application of all available evidence, when available, and not just the opinion of experts. This represented a seismic shift from a position of expert based consensus guidance to evidence led guidance for evolving clinical knowledge. The aim of this guide is to provide a practical approach to the development and application of a systematic review in medical education; a valid method used in this guide to seek and substantiate the effects of interventions in medical education.

The Canadian birth place study: examining maternity care provider attitudes and interprofessional conflict around planned home birth.

BACKGROUND: Available birth settings have diversified in Canada since the integration of regulated midwifery. Midwives are required to offer eligible women choice of birth place; and 25-30% of midwifery clients plan home births. Canadian provincial health ministries have instituted reimbursement schema and regulatory guidelines to ensure access to midwives in all settings. Evidence from well-designed Canadian cohort studies demonstrate the safety and efficacy of midwife-attended home birth. However, national rates of planned home birth remain low, and many maternity providers do not support choice of birth place. METHODS: In this national, mixed-methods study, our team administered a cross-sectional survey, and developed a 17 item Provider Attitudes to Planned Home Birth Scale (PAPHB-m) to assess attitudes towards home birth among maternity providers. We entered care provider type into a linear regression model, with the PAPHB-m score as the outcome variable. Using Students' t tests and ANOVA for categorical variables and correlational analysis (Pearson's r) for continuous variables, we conducted provider-specific bivariate analyses of all socio-demographic, education, and practice variables (n=90) that were in both the midwife and physician surveys. RESULTS: Median favourability scores on the PAPHB-m scale were very low among obstetricians (33.0), moderately low for family physicians (38.0) and very high for midwives (80.0), and 84% of the variance in attitudes could be accounted for by care provider type. Amount of exposure to planned home birth during midwifery or medical education and practice was significantly associated with favourability scores. Concerns about perinatal loss and lawsuits, discomfort with inter-professional consultations, and preference for the familiarity of the hospital correlated with less favourable attitudes to home birth. Among all providers, favourability scores were linked to beliefs about the evidence on safety of home birth, and confidence in their own ability to manage obstetric emergencies at a home birth. CONCLUSIONS: Increasing the knowledge base among all maternity providers about planned home birth may increase favourability. Key learning competencies include criteria for birth site selection, management of obstetric emergencies at planned home births, critical appraisal of literature on safety of home birth, and inter-professional communication and collaboration when women are transferred from home to hospital.

Engagement studios: students and communities working to address the determinants of health.

BACKGROUND: This article presents an innovative model for interprofessional community-oriented learning. The Engagement Studios model involves a partnership between community organizations and students as equal partners in conversations and activities aimed at addressing issues of common concern as they relate to the social determinants of health. METHODS: Interprofessional teams of students from health and non-health disciplines work with community partners to identify priority community issues and explore potential solutions. RESULTS: The student teams work with a particular community organization, combining their unique disciplinary perspectives to develop a project proposal, which addresses the community issues that have been jointly identified. Approved proposals receive a small budget to implement the project. DISCUSSION: In this paper we present the Engagement Studios model and share lessons learned from a pilot of this educational initiative.

Beyond religion and spirituality: faith in the study and practice of medicine.

Discussions about faith in medicine traditionally have been linked to religion and spirituality. Faith, however, is also that sense of trust or confidence one has in someone or something. As such, it is a concept integral to medical education and practice. This essay explores several dimensions of faith that play significant roles in medicine. It reviews why developing an awareness of faith is important for medical students and practitioners alike, and concludes by suggesting it is by seeking such faith in the profession that medical students and physicians can nurture their personal and professional growth.

"Do your homework and then hope for the best": the challenges that medical tourism poses to Canadian family physicians' support of patients' informed decision-making.

BACKGROUND: Medical tourism-the practice where patients travel internationally to privately access medical care-may limit patients' regular physicians' abilities to contribute to the informed decision-making process. We address this issue by examining ways in which Canadian family doctors' typical involvement in patients' informed decision-making is challenged when their patients engage in medical tourism. METHODS: Focus groups were held with family physicians practicing in British Columbia, Canada. After receiving ethics approval, letters of invitation were faxed to family physicians in six cities. 22 physicians agreed to participate and focus groups ranged from two to six participants. Questions explored participants' perceptions of and experiences with medical tourism. A coding scheme was created using inductive and deductive codes that captured issues central to analytic themes identified by the investigators. Extracts of the coded data that dealt with informed decision-making were shared among the investigators in order to identify themes. Four themes were identified, all of which dealt with the challenges that medical tourism poses to family physicians' abilities to support medical tourists' informed decision-making. Findings relevant to each theme were contrasted against the existing medical tourism literature so as to assist in understanding their significance. RESULTS: Four key challenges were identified: 1) confusion and tensions related to the regular domestic physician's role in decision-making; 2) tendency to shift responsibility related to healthcare outcomes onto the patient because of the regular domestic physician's reduced role in shared decision-making; 3) strains on the patient-physician relationship and corresponding concern around the responsibility of the foreign physician; and 4) regular domestic physicians' concerns that treatments sought abroad may not be based on the best available medical evidence on treatment efficacy. CONCLUSIONS: Medical tourism is creating new challenges for Canadian family physicians who now find themselves needing to carefully negotiate their roles and responsibilities in the informed decision-making process of their patients who decide to seek private treatment abroad as medical tourists. These physicians can and should be educated to enable their patients to look critically at the information available about medical tourism providers and to ask critical questions of patients deciding to access care abroad.

Accreditation in a sub Saharan medical school: a case study at Makerere University.

INTRODUCTION: Of more than the 2,323 recognized and operating medical schools in 177 countries (world wide) not all are subjected to external evaluation and accreditation procedures. Quality Assurance in medical education is part of a medical school's ethical responsibility and social accountability. Pushing this agenda in the midst of resource limitation, numerous competing interests and an already overwhelmed workforce were some of the challenges faced but it is a critical element of our medical profession's social contract. This analysis paper highlights the process of standard defining for Medical Education in a typically low resourced sub Saharan medial school environment. METHODS: The World Federation for Medical Education template was used as an operating point to define standards. A wide range of stakeholders participated and meaningfully contributed in several consensus meetings. Effective participatory techniques were used for the information gathering process and analysis. RESULTS: Standards with a clear intent to enhance education were set through consensus. A cyclic process of continually measuring, judging and improving all standards was agreed and defined. Examples of the domains tackled are stated. CONCLUSION: Our efforts are good for our patients, our communities and for the future of health care in Uganda and the East African region.

Canadian family doctors' roles and responsibilities toward outbound medical tourists: "Our true role is ... within the confines of our system".

OBJECTIVE: To explore how Canadian family doctors understand their roles and responsibilities toward patients who seek health care abroad. DESIGN: Six focus groups were held with family doctors across British Columbia to explore their experiences with and perspectives on outbound medical tourism. Focus groups were digitally recorded, transcribed, and subsequently thematically coded to discover common issues and themes across the entire data set. SETTING: Focus groups were held with family doctors in 6 cities in British Columbia that provided representation from all provincial health authorities and a range of urban contexts. PARTICIPANTS: A total of 22 currently practising family doctors participated across the 6 focus groups, with groups ranging in size from 2 to 6 participants (average 4 participants). METHODS: Thematic analysis of the transcripts identified cross-cutting themes that emerged across the 6 focus groups. MAIN FINDINGS: Participants reported that medical tourism threatened patients' continuity of care. Informational continuity is disrupted before patients go abroad because patients regularly omit family doctors from preoperative planning and upon return home when patients lack complete or translated medical reports. Participants believed that their responsibilities to patients resumed once the patients had returned home from care abroad, but were worried about not being able to provide adequate follow-up care. Participants were also concerned about bearing legal liability toward patients should they be asked to clinically support treatments started abroad. CONCLUSION: Medical tourism poses challenges to Canadian family doctors when trying to reconcile their traditional roles and responsibilities with the novel demands of private out-of-country care pursued by their patients. Guidance from professional bodies regarding physicians' responsibilities to Canadian medical tourists is currently lacking. Developing these supports would help address challenges faced in clinical practice.

Residency research requirements and the CanMEDS-FM scholar role: perspectives of residents and recent graduates.

OBJECTIVE: To explore the perspectives of family medicine residents and recent family medicine graduates on the research requirements and other CanMEDS scholar competencies in family practice residency training. DESIGN: Semistructured focus groups and individual interviews. SETTING: Family practice residency program at the University of British Columbia in Vancouver. PARTICIPANTS: Convenience sample of 6 second-year family medicine residents and 6 family physicians who had graduated from the University of British Columbia family practice residency program within the previous 5 years. METHODS: Two focus groups with residents and individual interviews with each of the 6 recently graduated physicians. All interviews were audiotaped, transcribed, and analyzed for thematic content. MAIN FINDINGS: Three themes emerged that captured key issues around research requirements in family practice training: 1) relating the scholar role to family practice, 2) realizing that scholarship is more than simply the creation or discovery of new knowledge, and 3) addressing barriers to integrating research into a clinical career. CONCLUSION: Creation of new medical knowledge is just one aspect of the CanMEDS scholar role, and more attention should be paid to the other competencies, including teaching, enhancing professional activities through ongoing learning, critical appraisal of information, and learning how to better contribute to the dissemination, application, and translation of knowledge. Research is valued as important, but opinions still vary as to whether a formal research study should be required in residency. Completion of residency research projects is viewed as somewhat rewarding, but with an equivocal effect on future research intentions.

Practice and payment preferences of newly practising family physicians in British Columbia.

OBJECTIVE: To examine the remuneration model preferences of newly practising family physicians. DESIGN: Mixed-methods study comprising a cross-sectional, Web-based survey, as well as qualitative content analysis of answers to open-ended questions. SETTING: British Columbia. PARTICIPANTS: University of British Columbia family practice residents who graduated between 2000 and 2009. MAIN OUTCOME MEASURES: Preferred remuneration models of newly practising physicians. RESULTS: The survey response rate was 31% (133 of 430). Of respondents, 71% (93 of 132) preferred non-fee-for-service practice models and 86% (110 of 132) identified the payment model as very or somewhat important in their choice of future practice. Three principal themes were identified from content analysis of respondents' open-ended comments: frustrations with fee-for-service billing, which encompassed issues related to aggravations with "the business side of things" and was seen as impeding "the freedom to focus on medicine"; quality of patient care, which embraced the importance of a payment model that supported "comprehensive patient care" and "quality rather than quantity"; and freedom to choose, which supported the plurality of practice preferences among providers who strived to provide quality care for patients, "whatever model you happen to be working in." CONCLUSION: Newly practising physicians in British Columbia preferred alternatives to fee-for-service payment models, which were perceived as contributing to fewer frustrations with billing systems, improved quality of work life, and better quality of patient care.

The social accountability of medical schools and its indicators.

CONTEXT: There is growing interest worldwide in social accountability for medical and other health professional schools. Attempts have been made to apply the concept primarily to educational reform initiatives with limited concern towards transforming an entire institution to commit and assess its education, research and service delivery missions to better meet priority health needs in society for an efficient, equitable an sustainable health system. METHODS: In this paper, we clarify the concept of social accountability in relation to responsibility and responsiveness by providing practical examples of its application; and we expand on a previously described conceptual model of social accountability (the CPU model), by further delineating the parameters composing the model and providing examples on how to translate them into meaningful indicators. DISCUSSION: The clarification of concepts of social responsibility, responsiveness and accountability and the examples provided in designing indicators may help medical schools and other health professional schools in crafting their own benchmarks to assess progress towards social accountability within the context of their particular environment.

Fly-By medical care: Conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists.

BACKGROUND: Medical tourism is a global health practice where patients travel abroad to receive health care. Voluntourism is a practice where physicians travel abroad to deliver health care. Both of these practices often entail travel from high income to low and middle income countries and both have been associated with possible negative impacts. In this paper, we explore the social responsibilities of medical tourists and voluntourists to identify commonalities and distinctions that can be used to develop a wider understanding of social responsibility in global health care practices. DISCUSSION: Social responsibility is a responsibility to promote the welfare of the communities to which one belongs or with which one interacts. Physicians stress their social responsibility to care for the welfare of their patients and their domestic communities. When physicians choose to travel to another county to provide medical care, this social responsibility is expanded to this new community. Patients too have a social responsibility to use their community's health resources efficiently and to promote the health of their community. When these patients choose to go abroad to receive medical care, this social responsibility applies to the new community as well. While voluntourists and medical tourists both see the scope of their social responsibilities expand by engaging in these global practices, the social responsibilities of physician voluntourists are much better defined than those of medical tourists. Guidelines for engaging in ethical voluntourism and training for voluntourists still need better development, but medical tourism as a practice should follow the lead of voluntourism by developing clearer norms for ethical medical tourism. SUMMARY: Much can be learned by examining the social responsibilities of medical tourists and voluntourists when they engage in global health practices. While each group needs better guidance for engaging in responsible forms of these practices, patients are at a disadvantage in understanding the effects of medical tourism and organizing responses to these impacts. Members of the medical professions and the medical tourism industry must take responsibility for providing better guidance for medical tourists.