Simulation-based medical education in Thailand: a cross-sectional online national survey.

BACKGROUND: Simulation-Based Medical Education (SBME) is a teaching method commonly used in undergraduate medical education. Although Thai medical schools have developed a system that incorporates SBME, various aspects of that system require improvement. We surveyed medical school administrators, instructors, and students about SBME in their institutions and the obstacles involved in its implementation, as well as their experiences, expectations, and attitudes regarding the current system. METHODS: We conducted a cross-sectional online survey between August 2019 and July 2020 among administrators, instructors, and 6th-year medical students. A structured questionnaire was developed and distributed to volunteers as an online survey. We recorded details about the SBME system as well as participant characteristics, obstacles, experiences, expectations, and attitudes. We used descriptive statistics as appropriate. RESULTS: We received responses from 15 (68.2%) administrators, 186 instructors, and 371 (13.7%) sixth-year medical students. SBME was commonly used in teaching and evaluation but less so in research. It was mainly used to improve psychomotor tasks, knowledge, patient care, and communication skills. The expected outcomes were improvements in students' performance, knowledge, and practice. The clinical courses were longer and had fewer participants than the pre-clinical courses. Obstacles encountered included shortages of faculty and simulators, time and space limitations, inadequate faculty training, and insufficient financial support. The administrators surveyed had positive attitudes toward SBME. Medical students reported having experience with SBME and strongly agreed that it was beneficial; however, they expected fewer students per class and more learning time to be devoted to these methods. CONCLUSIONS: SBME in Thailand is focused on teaching and assessment. The system could be improved through better-trained faculty, greater available space, more simulators, and sufficient funding. There were also some aspects that failed to meet students' expectations and need to be addressed. However, participants expressed positive attitudes toward SBME. TRIAL REGISTRATION: TCTR20210524003 (Thai Clinical Trials Registry).

From one-district-one-doctor to the inclusive track: Lessons learned from a 12-year special recruitment program for medical education in Thailand.

BACKGROUND: The One-District-One-Doctor (ODOD) medical education program was launched in 2005 with the purpose of increasing the production of rural doctors through special recruitment in Thailand. This article provides details of the ODOD program, together with its successes and challenges. Comparisons of the applied interventions between ODOD, the conventional rural recruitment program (Collaborative Project to Increase Production of Rural Doctors [CPIRD]), and the Inclusive track are also described. METHODS: Compared with the CPIRD program, additional interventions are applied to the ODOD program, including (1) recruitment from remote rural areas; (2) subsidized education in return for service; and (3) extended compulsory service in rural areas with a higher penalty fine. While ODOD students have shown a relatively high rural retention rate, the program challenges include low admission rate, adverse consequences from an extended compulsory service, restriction on specialist training, and high penalty fee. RESULTS: As a consequence of the program interventions, another special medical education program, the Inclusive track, was introduced as a replacement. Strategies through the Inclusive track to recruit students from remote rural areas are similar to those of ODOD. However, unlike ODOD, the Inclusive track has a reduced duration of compulsory service and penalty fine to match those of the standard requirements in the Normal track and CPIRD students. DISCUSSION: Building on past experience, the Inclusive track pursues a balance of pros and cons from the other medical production programs. Program evaluation and close monitoring will be crucial to measure the feedback from the Inclusive track to further improve the sustainability of long-term retention of rural physicians.

Community-based learning enhances doctor retention.

Background: Rural doctor shortage is a problem in many countries. Factors associated with doctor retention were reported such as colleagues, workload, accommodations, transportation, proximity of family and friends, incentives and career path. Rural background recruitment, increasing the quantity of doctor production to supply in rural and remote areas, and regulation are claimed to alleviate doctor scarcity in rural communities. Many programs have been developed, but an imbalance in physician distribution persists. Community-based learning (CBL) is recommended by the WHO to promote doctor retention. The longer contact time of CBL is practical, but it is uncertain that this results in greater retention. The objective of this study is to determine the association between contact time of CBL and retention of doctor with rural background recruitment. Methods: A cohort study was performed. The study population was 10,018 doctors graduated during 2001-2010 and followed up at least to 2014. Of the 10,018 physicians, 2098 doctors (21%) were recruited from rural backgrounds by the Collaborative Project to Increase Production of Rural Doctor (CPIRD). Contact time of CBL was calculated to the proportion of total curricular credit hours. The primary outcome was retention rate in government health-care system over 4 years. Statistical analysis was performed using multiple logistic regression. Results: A total of 5774 doctors (57.6%) were retained in the government health-care system. Higher percentages of CPIRD doctors were retained than normal track (72.1% and 53.8%, P < 0.001), especially in rural hospitals (60.3% and 38.4%, P < 0.001). Based on univariate analysis, CBL was slightly higher in retention than resignation group with statistical significance (2.97% and 2.90%, P = 0.045). Multiple logistic regression results showed that CBL, graduate entry, and geographic location of workplace were significantly associated with retention. Discussion: CBL can enhance doctor retention. It should incorporate meaningful experience such as rural exposure together with classroom teaching to focus concepts and integrating service to the community. Graduate entry and geographic location of workplace also have an impact on decision-making regarding retention.

The efficacy of ampicillin compared with ceftriaxone on preventing cesarean surgical site infections: an observational prospective cohort study.

Background: Cesarean surgical site infections (SSIs) can be prevented by proper preoperative antibiotic prophylaxis. Differences in antibiotic selection in clinical practice exist according to obstetricians' preferences despite clear guidelines on preoperative antibiotic prophylaxis. This study aimed to compare the efficacy of ampicillin and ceftriaxone in preventing cesarean SSIs. Methods: The observational prospective cohort study was conducted at a tertiary hospital in Thailand from 1 January 2007 to 31 December 2012. Propensity scores for ceftriaxone prophylaxis were calculated from potential influencing confounders. The cesarean SSI rates of the ceftriaxone group vs. those of the ampicillin prophylactic group were estimated by multilevel mixed-effects Poisson regression nested by propensity score. Results: Data of 4149 cesarean patients were collected. Among these, 911 patients received ceftriaxone whereas 3238 patients received ampicillin as preoperative antibiotic prophylaxis. The incidence of incisional SSIs was (0.1% vs. 1.2%; p = 0.001) and organ space SSIs was (1.2% vs. 2.9%; p = 0.003) in the ceftriaxone group compared with the ampicillin group. After adjusting for confounders, the rate ratios of incisional and organ/space SSIs in the ceftriaxone compared with the ampicillin group did not differ (RR, 0.23; 95% CI 0.03-1.78), and (RR, 1.62; 95% CI 0.83-3.18), respectively. Conclusion: These data indicate no difference exists between ampicillin and ceftriaxone to prevent SSIs after cesarean section. Ampicillin may be used as antibiotic prophylaxis in cesarean section.

Perception of educational environment among medical students in Thailand.

OBJECTIVES: To examine the perception of educational environment among clinical year students in Thailand using Dundee ready education environment measure (DREEM) and identify factors associated with the DREEM scores. METHODS: A total of 2,467 fourth- to sixth-year students from 34 teaching hospitals nationwide responded to a Thai version of DREEM questionnaire. Data on each student's sex, year of study, size of teaching hospitals and GPAX were collected. Mean total DREEM scores and subscales were calculated and then compared across groups using t-test and one-way ANOVA. RESULTS: The overall student perception on educational environment was 'more positive than negative,' with the mean total DREEM score of 131.1 (SD=17.4). Similar findings were observed in all subscales. Mean total DREEM scores were lower in medium-size than small- and large-size teaching hospitals 129.9 (SD = 18.1), 131.9 (SD = 17.5) and 131.6 (SD=16.4) respectively (F (2,2422)=3.21, p=0.04). Sex and years of study was associated with certain DREEM subscales. CONCLUSIONS: Clinical year medical students in Thailand were satisfied with their academic learning environment, with varying perceptions across different size of teaching hospitals. Repeat assessment of educational environment of medical schools over time is needed for monitoring changes after specific educational interventions being applied.

Retention of doctors in rural health services in Thailand: impact of a national collaborative approach.

INTRODUCTION: Little evidence exists about the impact of strategies to increase rural retention in developing countries. To address Thailand's long-lasting critical shortage of doctors, two new government-funded projects to increase the production of rural doctors have been employed through collaboration between the Ministry of Education and the Ministry of Public Health (MOPH). The present study describes the impact of this national collaborative approach on production and retention of doctors in rural health services. METHODS: In addition to a conventional track of medical training, a special recruitment initiative, including two special projects, called the Collaborative Project to Increase Production of Rural Doctor and One District One Doctor, were launched in 1994 and 2005 respectively. This special recruitment initiative involves partnership between 14 universities and 37 accredited hospitals in the MOPH. Doctor retention in the MOPH health services up to 1 June 2016 was compared across the two training tracks using χ2 test. Factors associated with 3-year retention in the MOPH health services were identified using multiple logistic regression. RESULTS: The overall and year-by-year retention of medical graduates under the special recruitment track was higher than the normal track (overall retention of 78.2% and 52.5% respectively, p<0.05). Compared to their normal track counterparts, medical graduates under the special recruitment scheme were about 2.4-fold more likely to remain working in the MOPH health services for a minimum period of 3 years (odds ratio 2.44, 95% confidence interval 2.19-2.72). Among 4869 medical graduates under the special recruitment track who remained working for the MOPH, 4425 (90.9%) still worked in the provinces to which they were primarily assigned. CONCLUSIONS: A national collaborative approach to increasing production of rural doctors was effective at enhancing retention of doctors in rural areas. Challenges remain to overcome uneven cross-region doctor density and maldistribution.

A Prognostic Scoring Tool for Cesarean Organ/Space Surgical Site Infections: Derivation and Internal Validation.

BACKGROUND: Organ/space surgical site infections (SSIs) are serious complications after cesarean delivery. However, no scoring tool to predict these complications has yet been developed. This study sought to develop and validate a prognostic scoring tool for cesarean organ/space SSIs. METHODS: Data for case and non-case of cesarean organ/space SSI between January 1, 2007 and December 31, 2012 from a tertiary care hospital in Thailand were analyzed. Stepwise multivariable logistic regression was used to select the best predictor combination and their coefficients were transformed to a risk scoring tool. The likelihood ratio of positive for each risk category and the area under receiver operating characteristic (AUROC) curves were analyzed on total scores. Internal validation using bootstrap re-sampling was tested for reproducibility. RESULTS: The predictors of 243 organ/space SSIs from 4,988 eligible cesarean delivery cases comprised the presence of foul-smelling amniotic fluid (four points), vaginal examination five or more times before incision (two points), wound class III or greater (two points), being referred from local setting (two points), hemoglobin less than 11 g/dL (one point), and ethnic minorities (one point). The likelihood ratio of cesarean organ/space SSIs with 95% confidence interval among low (total score of 0-1 point), medium (total score of 2-5 points), and high risk (total score of ≥6 points) categories were 0.11 (0.07-0.19), 1.03 (0.89-1.18), and 13.25 (10.87-16.14), respectively. Both AUROCs of the derivation and validation data were comparable (87.57% versus 86.08%; p = 0.418). CONCLUSIONS: This scoring tool showed a high predictive ability regarding cesarean organ/space SSIs on the derivation data and reproducibility was demonstrated on internal validation. It could assist practitioners prioritize patient care and management depending on risk category and decrease SSI rates in cesarean deliveries.

Rural retention of new medical graduates from the Collaborative Project to Increase Production of Rural Doctors (CPIRD): a 12-year retrospective study.

Physician scarcity in rural areas is a major obstacle to healthcare access, leading to health inequity worldwide. In Thailand, a special recruitment program of medical education [Collaborative Project to Increase Production of Rural Doctors (CPIRD)] was initiated with four different medical training tracks. No previous research has examined the rural retention of new medical graduates across the CPIRD tracks, compared with those receiving conventional medical education (Normal track). This study examines the public retention of rural physicians from different tracks of entry. A retrospective study was conducted in new medical graduates who entered Ministry of Public Health (MoPH) hospitals from January 2003 to October 2014, and followed up until June 2015, using administrative data from the Personnel Administration Division, MoPH. The CPIRD registry database was used to identify physicians' tracks of entry. Survival analyses and multiple logistic regression analyses were applied to compare the annual retention and the probability of 3-year retention of rural physicians. Results clearly demonstrated a high rural retention of CPIRD medical graduates, compared with their Normal track peers, regarding both lower annual resignation (HR 0.456, P < 0.001) and higher 3-year retention (OR 2.441, CI: 2.192, 2.719). Some variations of rural retention were revealed across the different CPIRD tracks. Evidence from this study can be used as part of the information to reshape the physician production policy to reduce health inequity in rural areas.

Risk factors for cesarean surgical site infections at a Thai-Myanmar border hospital.

BACKGROUND: Cesarean surgical site infections (SSIs) are a major challenge in Thai-Myanmar border hospital settings. This study aimed to examine risk factors for SSIs after cesarean section. METHODS: This was a prospective cohort study conducted in a Thai-Myanmar border hospital between January 2007 and December 2012. Data were collected from the medical record database by trained infection control nurses. Stepwise multivariable logistic regression was used for risk factor analysis and expressed as a risk ratio (RR). RESULTS: The cesarean SSI rate was 5.9% (293 SSIs in 4,988 cases). Of these, 17.1% were incisional SSIs (10.9% superficial and 6.2% deep incisional SSIs), and 82.9% were organ or space SSIs. Risk factors for cesarean organ-space SSIs included a wound class ≥3 (RR, 4.82; 95% confidence interval [CI], 3.41-6.83), ethnic minority (RR, 2.51; 95% CI, 1.61-3.92), hemoglobin <11 g/dL (RR, 2.19; 95% CI, 1.57-3.04), pelvic examination before delivery on ≥5 occasions (RR, 4.16; 95% CI, 2.89-5.99), preterm (RR, 1.98; 95% CI, 1.33-2.95), being a local referral (RR, 3.37; 95% CI, 2.29-4.97), and foul-smelling amniotic fluid (RR, 21.08; 95% CI, 10.23-43.41). CONCLUSIONS: Most cesarean SSIs in this study seem to have a high severity. Their risk factors reflected delayed appropriate perinatal maternal care that resulted in late cesarean delivery. Early prenatal care may help reduce cesarean SSIs among this population.

Universal screening of gestational diabetes mellitus: prevalence and diagnostic value of clinical risk factors.

OBJECTIVE: To estimate the prevalence of Gestational Diabetes Mellitus (GDM) by using universal screening and to show the diagnostic value of the clinical risk factors at Lampang Hospital. MATERIAL AND METHOD: This is a cross sectional study. Data were collected prospectively at the antenatal care clinic of Lampang Regional Hospital between January 4 and September 30, 2010. All pregnant women of appropriate gestational age (GA) were screened by glucose challenge test (GCT) then by oral glucose tolerance test (OGTT) if the GCT result was abnormal. Data were calculated for the prevalence of GDM and the diagnostic value of clinical risk factors. RESULTS: Six hundred thirteen pregnant women enrolled into the present study with 593 women left for the analysis. The prevalence of GDM at antenatal care clinic of Lampang Hospital was 9.3%. Among GDM cases, 21.8% had no risk factor Having one risk factor double the chance of having GDM, while having three risk factors gives 42.9% chance of having GDM. Having at least one risk factor could allow better detection with sensitivity of 78.2, specificity of 49.8, PPV of 13.7, NPV of 95.7, LR+ of 1.6 and LR- of 0.4. This would produce 52.8% of pregnant women at risk. CONCLUSION: With GDM prevalence of 9.3%, our population should be classified to the high prevalence group. Among GDM cases, 21.8% had no risk factor. Moreover with 95.7% NPV and 0.4 LR-, this would make this set of risk factors merely a fair screening test. This should prompt the re-evaluation of risk-based screening policy that is generally adopted throughout the country. Cost-effectiveness is the only major concern for the deployment of the universal screening program. It has to be further studied in an evidence-based manner.

Fundal height growth curve for underweight and overweight and obese pregnant women in Thai population.

Objectives. To develop fundal height growth curves for underweight and overweight and obese pregnant women based on gestational age from last menstrual period and/or ultrasound. Methods. A retrospective study was conducted at four hospitals in the northern part of Thailand between January 2009 and March 2011. Fundal height, gestational age, height, and prepregnancy weight were extracted from antenatal care and delivery records. Fundal height growth curves were presented as smoothed function of the 10th, 50th, and 90th percentiles between 20 and 40 weeks of gestation, derived from multilevel models. Results. Fundal height growth curve of the underweight was derived from 1,486 measurements (208 women) and the overweight and obese curve was derived from 1,281 measurements (169 women). The 50th percentile line of the underweight was 0.1-0.4 cm below the normal weight at weeks 23-31 and 0.5-0.8 cm at weeks 32-40. The overweight and obese line was 0.1-0.4 cm above the normal weight at weeks 22-29 and 0.6-0.8 cm at weeks 30-40. Conclusions. Fundal height growth curves of the underweight and overweight and obese pregnant women were different from the normal weight. In monitoring or screening for abnormal intrauterine growth in these women, fundal height growth curves specifically developed for such women should be applied.