Medicine on the margins: learning opportunities for undergraduates within inclusion health.

Marginalised groups, including the homeless, refugees and asylum seekers, often experience extremely poor health and present unique challenges to health systems. Undergraduate medical placements with specialist primary care services for these groups can be an insightful learning opportunity within 'inclusion health', a field committed to improving health of these populations. The aim of this project was to showcase organisations for students to gain further exposure and evaluate students' elective experiences at a specialist primary care service for marginalised groups. Students created a mind map to identify organisations in Norwich that were valuable for future students to explore. Five elective students were asked to complete qualitative questionnaires about their experiences. Approximately 10 organisations accommodated participating medical students. Three of five participants responded to the questionnaire, reporting a beneficial learning experience, enabling students to understand complex needs of marginalised groups. The findings offer creative suggestions of where students can gain further exposure. Evaluation of this elective suggests there is unique value in offering placements with a diverse range of organisations that support marginalised groups. Educators should consider integrating opportunities for debriefing and a structured curriculum. Greater support and resources must be provided to include these services for regular teaching and training.

Online patient simulation training to improve clinical reasoning: a feasibility randomised controlled trial.

BACKGROUND: Online patient simulations (OPS) are a novel method for teaching clinical reasoning skills to students and could contribute to reducing diagnostic errors. However, little is known about how best to implement and evaluate OPS in medical curricula. The aim of this study was to assess the feasibility, acceptability and potential effects of eCREST - the electronic Clinical Reasoning Educational Simulation Tool. METHODS: A feasibility randomised controlled trial was conducted with final year undergraduate students from three UK medical schools in academic year 2016/2017 (cohort one) and 2017/2018 (cohort two). Student volunteers were recruited in cohort one via email and on teaching days, and in cohort two eCREST was also integrated into a relevant module in the curriculum. The intervention group received three patient cases and the control group received teaching as usual; allocation ratio was 1:1. Researchers were blind to allocation. Clinical reasoning skills were measured using a survey after 1 week and a patient case after 1 month. RESULTS: Across schools, 264 students participated (18.2% of all eligible). Cohort two had greater uptake (183/833, 22%) than cohort one (81/621, 13%). After 1 week, 99/137 (72%) of the intervention and 86/127 (68%) of the control group remained in the study. eCREST improved students' ability to gather essential information from patients over controls (OR = 1.4; 95% CI 1.1-1.7, n = 148). Of the intervention group, most (80/98, 82%) agreed eCREST helped them to learn clinical reasoning skills. CONCLUSIONS: eCREST was highly acceptable and improved data gathering skills that could reduce diagnostic errors. Uptake was low but improved when integrated into course delivery. A summative trial is needed to estimate effectiveness.

Humanising medicine: teaching on tri-morbidity using expert patient narratives in medical education.

Expert patients have recognised benefits for both students and patients in medical education. However, marginalised patients such as homeless patients are less likely to participate. Learning from such individuals is crucial for future doctors, who can, in turn, aid their inclusion in society and improve access to health care. A 'humanising medicine' lecture was delivered to Year Four medical students at Norwich Medical School. The lecture utilised narratives from patients with experience of homelessness and tri-morbidity (physical and mental health problems and substance abuse). We used a qualitative approach to evaluate this teaching and understand the experience of both students and patients. Students were asked to complete questionnaires, whereas expert patients were interviewed. We thematically analysed data using an inductive approach. Students reported an increased understanding, empathy and preparedness to consult with marginalised patients. Expert patients described positive feelings about their involvement, giving something back, and the therapeutic benefits of telling their story. We found that including marginalised patients in medical education had positive benefits for both students and patients. Our findings suggest that expert patient narratives are valuable in medical education particularly in teaching and learning about medical complexity and tri-morbidity.

"Taking from Peter to pay Paul": The experience of people in receipt of fuel and food vouchers from a UK foodbank.

For people on very low incomes, household fuel and food environments are increasingly uncertain. Many live in precarious situations with little control over their lives. In addition to food parcels, many foodbanks also supply emergency fuel payments. There has been a surge in demand due to the cost of living crisis in the United Kingdom. This qualitative study, using semi-structured interviews, explored the lived experience of people who received a fuel voucher via a foodbank to gain insights into food preparation, eating practices and heating and appliance use in their homes. All participants (n = 6) described a change in life circumstances leaving them at crisis point with overwhelming uncertainty. Using Thematic Analysis, we identified four themes: (1) Bewilderment in using foodbank services; (2) The need to make trade-offs between food and fuel; (3) Feeling shame at using the services and (4) Missing out on pleasurable eating practices. Three case studies give fuller insights and context. All interviewees had acute and complex needs and described being 'at rock bottom', with fuel vouchers viewed as a 'lifeline' to address essential cooking, heating and electrical appliance needs. We, therefore, suggest the need for extra support and follow-up for first-time users who are in a state of denial and shock when seeking help. Further research is needed on how to best help organisations develop strategies to address and ameliorate a sense of powerlessness and shame felt by their clients which likely limits them from seeking help, despite being in acute, complex and dire need.

From evidence to practice: Developing best practice guidelines for the delivery of activities to people living with moderate to advanced dementia using a pragmatic observational study.

The benefits of physical activities for those living with moderate to advanced dementia are well documented and include improved well-being and quality of life. What is less well known is how best to deliver such activities to make them meaningful for those taking part and, more generally, how to develop good practice guidance for working with this group. This article reports on an observational study of a physical activity programme in a residential care setting, Mobile Me, and on the process used to develop good practice guidance from it, which included input from a range of stakeholders. Learnings from this study conclude that changes in delivery and setting can contribute to a difference in the quality of the experience for participants and their levels of well-being during sessions. The findings from the study were consolidated into four themes for disseminating best practice: promoting the right atmosphere, environment, communication, and adaptations. These form part of a new multimedia best practice guide for delivering physical activities to those living with moderate to advanced dementia.

Evaluating a specialist primary care service for patients experiencing homelessness: a qualitative study.

BACKGROUND: People experiencing homelessness (PEH) often experience poor health, multimorbidity, and early mortality and experience barriers to accessing high quality health care. Little is known about how best to provide specialist primary care for these patients. AIM: To evaluate the health care provided to patients experiencing homelessness who were seen in a specialist primary care service. DESIGN & SETTING: A qualitative evaluation of a city centre primary healthcare service for excluded and vulnerable people, such as rough sleepers, who find it difficult to visit mainstream GP services. METHOD: Data on patient characteristics and service use were extracted from primary care records using electronic and free-text searches to provide context to the evaluation. Semi-structured interviews with 11 patients and four staff were used to explore attitudes and experiences. RESULTS: Patients had high needs compared with the general population. Patients valued continuity of care, ease of access, multidisciplinary care, and person-centred care. Staff were concerned that they lacked opportunities for reflection and learning, and that low clinical capacity affected service safety and quality. Staff also wanted more patient involvement in service planning. CONCLUSION: PEH's complex health and social problems benefited from a specialist primary care service, which is thought to reduce barriers to access, treat potentially challenging patients in a non-judgmental way, and provide personal continuity of care in order to develop trust.

A Longitudinal Pathway for Clinical Educators: a Case Study.

This article was migrated. The article was marked as recommended. It is increasingly being recognised that medical education research and scholarship are essential if we are to provide innovative, research-informed teaching to medical students. Developing a discrete pathway for the professional development of clinical educators side by side with clinical training would enable such training to be offered to high caliber candidates. However, the challenges faced by clinical educators trying to deliver both the clinical and educational components of their training to a high standard must not be underestimated. In addition, employing institutions need to consider and agree criteria for career progression of these clinical academics. Identifying a mentor who can guide professional development is crucial, particularly in the early stages.