'Virtually daily grief'-understanding distress in health practitioners involved in a regulatory complaints process: a qualitative study in Australia.

Protection of the public is the paramount aim for health practitioner regulation, yet there has been growing concern globally on the association between regulatory complaints processes and practitioner mental health and wellbeing. The objective was to understand the experience, particularly distress, of health practitioners involved in a regulatory complaints process to identify potential strategies to minimise future risk of distress. Semi-structured qualitative interviews were conducted with health practitioners in Australia who had recently been through a regulatory complaints process, together with a retrospective analysis of documentation relating to all identified cases of self-harm or suicide of health practitioners who were involved in such a process over 4 years. Data from interviews and the serious incident analysis found there were elements of the regulatory complaints process contributing to practitioner distress. These included poor communication, extended time to close the investigation, and the management of health-related concerns. The study found external personal circumstances and pre-existing conditions could put the practitioner at greater risk of distress. There were found to be key moments in the process-triggers-where the practitioner was at particular risk of severe distress. Strong support networks, both personal and professional, were found to be protective against distress. Through process improvements and, where appropriate, additional support for practitioners, we hope to further minimise the risk of practitioner distress and harm when involved in a regulatory complaints process. The findings also point to the need for improved partnerships between regulators and key stakeholders, such as legal defence organisations, indemnity providers, employers, and those with lived experience of complaints processes. Together they can improve the support for practitioners facing a complaint and address the stigma, shame, and fear associated with regulatory complaints processes. This project provides further evidence that a more compassionate approach to regulation has the potential to be better for all parties and, ultimately, the wider healthcare system.

How was the intern year?: self and clinical assessment of four cohorts, from two medical curricula.

BACKGROUND: Problem-based curricula have provoked controversy amongst educators and students regarding outcome in medical graduates, supporting the need for longitudinal evaluation of curriculum change. As part of a longitudinal evaluation program at the University of Adelaide, a mixed method approach was used to compare the graduate outcomes of two curriculum cohorts: traditional lecture-based 'old' and problem-based 'new' learning. METHODS: Graduates were asked to self-assess preparedness for hospital practice and consent to a comparative analysis of their work-place based assessments from their intern year. Comparative data were extracted from 692 work-place based assessments for 124 doctors who graduated from the University of Adelaide Medical School between 2003 and 2006. RESULTS: Self-assessment: Overall, graduates of the lecture-based curriculum rated the medical program significantly higher than graduates of the problem-based curriculum. However, there was no significant difference between the two curriculum cohorts with respect to their preparedness in 13 clinical skills. There were however, two areas where the cohorts rated their preparedness in the 13 broad practitioner competencies as significantly different: problem-based graduates rated themselves as better prepared in their 'awareness of legal and ethical issues' and the lecture-based graduates rated themselves better prepared in their 'understanding of disease processes'.Work-place based assessment: There were no significant differences between the two curriculum cohorts for 'Appropriate Level of Competence' and 'Overall Appraisal'. Of the 14 work-place based assessment skills assessed for competence, no significant difference was found between the cohorts. CONCLUSIONS: The differences in the perceived preparedness for hospital practice of two curriculum cohorts do not reflect the work-place based assessments of their competence as interns. No significant difference was found between the two cohorts in relation to their knowledge and clinical skills. However results suggest a trend in 'communication with peers and colleagues in other disciplines' (χ2 (3, N = 596) =13.10, p = 0.056) that requires further exploration. In addition we have learned that student confidence in a new curriculum may impact on their self-perception of preparedness, while not affecting their actual competence.

Standard setting of script concordance tests using an adapted Nedelsky approach.

BACKGROUND: Standard setting in assessment seeks to apply meaning of achievement to an assessment score. Appropriate standard setting for script concordance tests (SCTs) remains a challenge, with existing methods representing norm-referenced approaches. AIMS: To develop a criterion-referenced standard setting approach for sct using an adapted nedelsky approach, to pilot feasibility, and to compare failure rates with two other methods. METHODS: Second- and third-year medical students were administered a 45-question SCT and results collated. Standard setting was applied using three approaches: (1) norm-referenced (student cohorts), (2) expert-referenced (student cohort compared to expert mean), and (3) adapted Nedelsky approach using answer key normalization. Feasibility and failure rates were measured. RESULTS: All standard setting approaches were feasible, with 60 additional minutes required for the Nedelsky standard setting exercise. Failure rates between the three approaches were similar (Year 2: 8.0-9.8% and Year 3: 2.1-7.6%), with the adapted Nedelsky approach representing an intermediate option (Year 2: 8.0% and Year 3: 3.5%). CONCLUSION: Standard setting SCT using the criterion-referenced method of an adapted Nedelsky approach was found to be both logically justifiable and logistically simple, and produced failure rates comparable to other currently utilized and less objective approaches.

Tomorrow's educators today? Implementing near-peer teaching for medical students.

BACKGROUND: The University of Adelaide offers a six-year undergraduate medical degree with a focus on small group learning. Senior medical students had previously received limited formal training in education skills, and were identified as an underutilised teaching resource. AIMS: To devise a programme in which senior students are exposed to the various facets of university teaching responsibilities and to evaluate its impact on both the tutors and the students. METHODS: A six week rotation in medical education for final year medical students was designed and implemented in 2010 to involve them in the development, delivery and assessment of the 1st and 2nd year medical programme as near-peer tutors (NPTs). RESULTS: Two years after the rotation's implementation, voluntary evaluation of both the junior students and NPTs was undertaken through a mixed methods approach of survey and focus group. Junior students (n=358) revealed the NPTs provided non-threatening learning environments, provided helpful feedback and acted as role models. Additionally, the NPTs (n=24) reported they had consolidated prior knowledge, developed their teaching skills and expressed a desire to be more involved in teaching in the future. CONCLUSIONS: The implementation of NPTs in the teaching of junior medical students appears to benefit both students and their near-peer colleagues. Involvement of NPTs in all facets of medical education through this rotation stands to not only foster potential interest in an academic pathway but also equip them with a variety of transferable skills which they can draw on as future educators in their profession.

Clinical reasoning - a guide to improving teaching and practice.

BACKGROUND: The process of clinical reasoning is undertaken by all clinicians, often automatically, and is the cognitive process that underlies diagnosis and management of a patient's presenting problem. The teaching of clinical reasoning can pose a challenge to the clinical teacher. OBJECTIVE: This article reviews the process of clinical reasoning and provides the teacher with a framework to teach clinical reasoning to students and junior doctors. DISCUSSION: By considering clinical reasoning as a skill to be learnt rather than a concept to be understood, a framework for teaching this skill can be developed. The learner initially observes a consultation by the teaching clinician, followed by the teacher explaining the reasoning processes used including hypothesising, hypothesis testing, re-analysis and differential diagnosis. The student then comments on the reasoning of the teacher in a subsequent consultation, followed by feedback from the teacher on the student's reasoning in a third consultation.

The educational value of Disaster Victim Identification (DVI) missions-transfer of knowledge.

Transfer of knowledge is the cornerstone of any educational organisation, with senior staff expected to participate in the training of less experienced colleagues and students. Teaching in the field is, however, slightly different, and a less theoretical approach is usually recommended. In terms of Disaster Victim Identification (DVI) activities, practical work under supervision of a field team stimulates tactile memory. A more practical approach is also useful when multiple organizations from a variety of countries are involved, as language barriers make it easier to manually show someone how to solve a problem, instead of attempting to explain complex concepts verbally. "See one, do one, teach one" is an approach that can be used to ensure that teaching is undertaken with the teacher grasping the essentials of a situation before passing on the information to someone else. The key principles of adult learning that need to be applied to DVI situations include the following: participants need to know why they are learning and to be motivated to learn by the need to solve problems; previous experience must be respected and built upon and learning approaches should match participants' background and diversity; and finally participants need to be actively involved in the learning process. Active learning involves the active acquisition of knowledge and/or skills during the performance of a task and characterizes DVI activities. Learning about DVI structure, activities and responsibilities incorporates both the learning of facts ("declarative knowledge") and practical skills ("procedural knowledge"). A fundamental requirement of all DVI exercises should be succession planning with involvement of less experienced colleagues at every opportunity so that essential teaching and learning opportunities are maximized. DVI missions provide excellent teaching opportunities and international agencies have a responsibility to teach less experienced colleagues and local staff during deployment.

Poor outcome after liver transplantation for transthyretin amyloid neuropathy in a family with an Ala36Pro transthyretin mutation: case report.

Transthyretin amyloid polyneuropathy, caused by mutations in the transthyretin gene, is a progressive condition for which liver transplantation is an established treatment. Favorable outcomes have been described in patients with the most common transthyretin mutation, Val30Met, but outcomes have been variable in patients with other mutations. We describe the cases of 2 siblings with transthyretin amyloid polyneuropathy secondary to an infrequently reported transthyretin mutation (Ala36Pro) who underwent liver transplantation with poor outcomes.

Distress levels and self-reported treatment rates for medicine, law, psychology and mechanical engineering tertiary students: cross-sectional study.

OBJECTIVE: The aim of this research was to assess tertiary student distress levels with regards to (i) comparisons with normative population data, and (ii) the effects of discipline, year level, and student characteristics. Self-reported treatment rates and level of concern regarding perceived distress were also collected. METHOD: Students from all six years of an undergraduate medical course were compared with samples from Psychology, Law and Mechanical Engineering courses at the University of Adelaide, Australia. Students participated in one of three studies that were either web-based or paper-based. All studies included Kessler's Measure of Psychological Distress (K10), and questions pertaining to treatment for any mental health problems and concern regarding distress experienced. RESULTS: Of the 955 tertiary students who completed the K10, 48% were psychologically distressed (a K10 score > or = 22) which equated to a rate 4.4 times that of age-matched peers. The non-health disciplines were significantly more distressed than the health disciplines. Distress levels were statistically equivalent across all six years of the medical degree. Of tertiary students, 11% had been treated for a mental health problem. Levels of concern correlated with the K10 score. CONCLUSION: The results from this research suggest that high distress levels among the tertiary student body may be a phenomenon more widely spread than first thought. Low treatment rates suggest that traditional models of support may be inadequate or not appropriate for tertiary cohorts.

Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients.

OBJECTIVES: Peer-assisted learning (PAL) has been reported to have educational benefits in cross-year, small-group teaching in other contexts. Accordingly, we explored whether senior medical students are effective tutors for their junior peers in clinical skills education, and how the participants in the learning triad (tutors, learners and simulated patients [SPs]) perceive the learning environment created in PAL. METHODS: Year 2 students were randomly allocated to one of two groups for skills training. Group 1 (n = 64) were tutored by volunteer Year 6 students, and Group 2 (n = 67) by paid doctors. The results of both groups in a clinical skills examination were compared using an independent samples t-test. Qualitative data, obtained from Year 2 students (n = 125) by written questionnaire and Year 6 students (n = 11) and SPs (n = 3) by focus group interviews, were analysed for themes. RESULTS: Students receiving PAL did at least as well in the clinical skills examination as students with qualified tutors (difference in mean total score: 0.7 marks out of 112; 95% confidence interval--8 to 2.4). The PAL environment was perceived as 'comfortable' and fostered the development of confidence in all participants. Peer tutors created a more active learning environment than doctor tutors for both learners and SPs and reported personal benefits from teaching. CONCLUSIONS: With appropriate support, volunteer Year 6 student tutors are as effective as graduate doctors for small-group structured tutorials in clinical skills. Educational relationships were forged between all participants in the learning triad.

The assessment of student reasoning in the context of a clinically oriented PBL program.

BACKGROUND: Doctors' clinical reasoning ability significantly impacts upon their level of clinical competence. Throughout medical training students are given the opportunity to develop their reasoning ability in order to become appropriately clinically competent by graduation. AIM: To develop an instrument to assess students' reasoning ability on a written case-based question which was aligned to their learning in a PBL program. METHOD: An instrument with 10 criteria centred upon hypothesis generation, learning issues and mechanistic explanations was developed. Experienced clinical and medical educators validated the instrument, prior to its use with 145 undergraduate first-year medical students. RESULTS: The results enabled the establishment of the strengths and weaknesses in the reasoning performances of individuals, as well as the overall cohort. The instrument's Cronbach alpha coefficient was 0.94, and it had high inter-rater and intra-rater reliability. Further validation of the instrument's performance was established through qualitative evidence derived from student interviews and tutor reports for this cohort. CONCLUSIONS: Aligning written assessment to the PBL process enables students and teachers to better understand how the reasoning process is developing for individuals and a cohort, and provides a basis for further investigation into the development of student clinical reasoning.

Overuse of antidepressant drugs for the treatment of depression.

The problem of under-diagnosis and under-treatment of depression has been identified as a major public health issue and measures have been taken to increase the recognition of depression and its treatment with antidepressants. The possibility of harm from the overuse of antidepressants has attracted far less attention. This review sets out evidence to show that inappropriate use of antidepressants (i.e. outside clinical indications, in excessive doses and for prolonged periods) constitutes a concerning public health problem. Antidepressant prescribing increased by between 4- and 10-fold in various age groups and countries in the last decade of the 20th century. The population of severely depressed patients (in whom antidepressants are accepted to be an effective treatment) who are not receiving antidepressants is probably much smaller than the population receiving these drugs inappropriately. We sound a note of caution for depression awareness campaigns. These apparently well-reasoned responses to the perceived under-recognition of depression can exacerbate over-prescribing. Unless prescribing patterns change, any benefits from increasing access to antidepressants for those with severe depression will be accompanied by significant harms due to inappropriate prescribing in conditions, such as mild depression, where antidepressants are not indicated.

Intraduodenal guar attenuates the fall in blood pressure induced by glucose in healthy older adults.

OBJECTIVES: Postprandial hypotension occurs frequently in older people and may result in syncope and falls. It has recently been established that the magnitude of the fall in blood pressure is related to the rate at which glucose enters the small intestine. We addressed the hypothesis that the fall in blood pressure induced by an intraduodenal glucose infusion is influenced by the interaction of glucose with the small intestinal absorptive epithelium. METHODS: Eight healthy older participants (four male, four female, age 70.3 +/- 3.4 years) were studied on two separate occasions, in single-blind, randomized order. Participants received an intraduodenal glucose infusion (3 kcal/min) with or without guar gum (4 g) for 60 minutes (0-60 minutes), followed by 0.9% saline intraduodenally for a further 60 minutes (60-120 minutes). Blood pressure and heart rate were measured every 3 minutes. Levels of blood glucose, plasma insulin, glucagon-like peptide-1 (GLP-1), and glucose-dependant insulinotropic-polypeptide (GIP) were also determined. RESULTS: Between t = 0 and t = 30 minutes, the magnitude of the fall in systolic blood pressure (p =.03) and increase in heart rate (p =.027) were lower after guar. The blood glucose (p =.009), plasma insulin (p =.027), plasma GLP-1 (p =.018), and GIP (p <.001) responses to intraduodenal glucose were attenuated by guar. CONCLUSIONS: In healthy older participants, the magnitude of the fall in systolic blood pressure and increase in heart rate induced by intraduodenal glucose are attenuated when the exposure of glucose to the small intestinal mucosa and subsequent glucose absorption is slowed by guar.

Single-enantiomer drugs: elegant science, disappointing effects.

Most new drugs are marketed as single enantiomers but many older agents are still available in racemic form. As these drugs reach the end of their patent life manufacturers become interested in marketing single enantiomer equivalents. This is called 'chiral switching' and it has been claimed that it will bring clinical benefits in terms of improved efficacy, more predictable pharmacokinetics or reduced toxicity. We reviewed the clinical evidence and prices for three recently marketed single enantiomer versions of widely used racemic drugs: escitalopram, esomeprazole and levosalbutamol. Claims of increased efficacy were based on comparisons of non-equivalent doses and any advantages seemed small and clinically unimportant. Prices of esomeprazole and levosalbutamol were higher than their racemic alternatives and we predict that these prices will remain high despite the market presence of generic versions of the racemates. Patent protection and a perception of superiority based on promotion rather than evidence will maintain price premiums for single enantiomer drugs that are not justified on the basis of clinical performance.

Combination pharmacotherapy for psychiatric disorders in children and adolescents: prevalence, efficacy, risks and research needs.

Polypharmacy, defined as the concomitant use of two or more psychotropic drugs, has become increasingly common in the paediatric and adolescent population over the past two decades. Combining psychotropic drugs leads to possible increases in benefits, but also in risks, particularly given the potential for psychotropic drug interactions. Despite the increasing use of concomitant therapy in children and adolescents, there is very little evidence from controlled clinical trials to provide guidance for prescribers. Even while acknowledging the small evidence base, clinical practice guidelines from eminent medical organizations are either relatively silent on or tend to support the use of concomitant treatments more enthusiastically than the evidence would warrant, so that practice and guidance are running ahead of the science. Our narrative review shows that the published evidence for efficacy and safety of concomitant psychotropic drugs in children and adolescents is scanty. A comprehensive search located 37 studies published over the last decade, of which 18 were randomized controlled trials (RCTs). These focused mainly on stimulants, central sympatholytics (such as clonidine), antipsychotics and 'mood stabilizers'. While several small, often methodologically weak, RCTs demonstrated statistically significant advantages for dual pharmacotherapy over monotherapy, only adding central sympatholytics to stimulants for treating attention-deficit hyperactivity disorder (ADHD) symptoms was supported by substantial studies with an effect size large enough to suggest clinical importance. Non-randomized studies tended to have results that supported concomitant treatment, but all have design-related problems that decrease the reliability of the results. Two studies that specifically examined tolerability of combination pharmacotherapy compared with monotherapy showed significant increases in adverse effects, both subjective and objective, and other studies confirmed a statistically significant increase in adverse effects, including sedation and self-harm. Given the extent of combination therapy occurring, particularly in conditions such as ADHD, and the ambiguous evidence for benefit with clear evidence of harm, we propose that further research should be carried out as a matter of urgency. Until such a time, the attitude to combination pharmacotherapy should be conservative, and combining psychotropic medications should be considered as an 'n of 1' trial to be closely monitored.

Predictive factors for treatment retention in methadone programs in Indonesia.

This article presents the results of a 6-month prospective cohort study of methadone maintenance treatment (MMT) in Indonesia. The study aimed to investigate the predictor variables of retention in MMT in Indonesia. The duration of treatment (in days) was the main outcome of the study. For the study, program, client, social network, and accessibility factors were investigated as potential predictors of retention. The study analyzed the relative weight of each factor in predicting treatment retention. The sample consisted of 178 clients drawn from three participating clinics: Rumah Sakit Ketergantungan Obat and Tanjung Priok in Jakarta and Sanglah in Bali. The 3- and 6-month retention rates were 74.2% and 61.3%, respectively. These rates are comparable with previous studies conducted in developed countries. A survival analysis using a robust estimation for the Cox PH regression found that the strongest predictors of retention were methadone dose followed by an interaction between take-home dose and the experience of the clinic providing this treatment. Other significant predictor variables included age, perceived clinic accessibility, and client's belief in the program. The study concludes that MMT cannot solely rely on the pharmacology for retention but should also promote informed access to take-home doses.

Bilateral bulbar palsy and postural hypotension following surgery for fourth ventricle subependymoma.

We report a 54-year-old man who developed bilateral bulbar palsy and severe postural hypotension following resection of a fourth ventricle subependymoma. It is proposed that interruption of the function of the nucleus of the tractus solitarius (in which the baroreflex is integrated) may have been responsible for the postural hypotension.