A value analysis of longitudinal integrated clerkships: consideration of costs and benefits.

Longitudinal Integrated Clerkships (LICs) prioritise longitudinal relationships with faculty, patients, and place. Research shows that LICs benefit students and faculty, but most medical schools have limited LIC programmes. This is likely due to perceptions that LICs are more costly and complex than traditional block rotations (TBRs). The perceived cost versus evidence-based value related to clerkship education has not been examined in detail. Until recently, no 'All-LIC' medical school exemplars existed in the US, limiting the value of this model as well as the ability to examine relative cost and complexity. In this paper, we draw on our experience launching three 'All-LIC' medical schools in the United States - schools in which the entire clerkship class participates in a comprehensive clerkship-year LIC. We propose that the known benefits of LICs coupled with cost-mitigation strategies related to running an 'All LIC' model for core clinical clerkships, rather than block and LIC models simultaneously, results in a higher value for medical schools.

An Interactive Online Interprofessional Opioid Education Training Using Standardized Patients.

Introduction: Opioid pain management is complex and requires a collaborative approach. To prepare health professions students to care for patients who have chronic pain, we developed an interprofessional education (IPE) session for delivery using a virtual platform that featured a standardized patient (SP) interaction. Methods: The SP case highlighted a patient on opioids for chronic low back pain resulting from a car accident. Despite no improvement in pain or function, the patient continued taking opioids and developed behaviors that could represent opioid misuse. During the synchronous, online session, interprofessional teams of students interviewed an SP and collaborated to develop a holistic care plan to address the patient's pain and potential opioid misuse. The session evaluation included pre- and postsession surveys. Results: Over 750 students from medicine, pharmacy, nursing, and social work programs participated in the virtual IPE sessions during a single year. Students rated the session positively. Matched survey responses suggested improved confidence in knowledge and skills, and learning through Zoom was rated favorably. Discussion: We successfully implemented a synchronous online IPE session involving SP interactions that allowed students to practice team-based care of a patient with chronic pain who was taking opioids. Based on the success of this IPE session, including the success of the online delivery model, future IPE sessions will continue virtually.

Interprofessional Education to Address Substance Use among Adults with Persistent Pain: A Pre-Post Program Evaluation.

BACKGROUND: Substance use disorders (SUDs) are highly prevalent among adults with persistent pain. Yet, standard competencies for integrating pain and SUD content are lacking across health science student curricula. Additionally, pharmacotherapies to treat SUDs are underutilized. AIM: To address these gaps, a team of health science faculty created an interprofessional simulation activity using a standardized patient and evaluated learner outcomes related to assessment and treatment of comorbid persistent pain and substance use. METHODS: A total of 304 health science students representing nursing, medicine, pharmacy, and social work programs attended virtual learning sessions. Interprofessional student teams developed a team-based care plan for an adult with musculoskeletal pain who takes prescribed opioids while using alcohol. Pre- and post-activity surveys assessing knowledge and confidence were matched for 198 students. Descriptive statistics summarized survey data with inferential analysis of paired data. RESULTS: The largest significant improvements between pre- and post-activity knowledge were observed in items specific to pharmacotherapy options for alcohol and opioid use disorders. Similar gains were noted in students' confidence regarding pharmacotherapies. No significant differences were noted on pre-post-activity knowledge scores between the three main profession groups (medicine, nursing, and pharmacy). CONCLUSIONS: Students attending this interprofessional simulation demonstrated improved knowledge and confidence, particularly in pharmacotherapies for alcohol and opioid use disorders. Replication of such programs can be used to provide consistent content across health science disciplines to heighten awareness and receptivity to medications available to treat SUDs in people treated for persistent pain. The curriculum is freely available from the corresponding author.

Facilitating credentialing and engagement of international physician-migrants during the COVID-19 crisis and beyond.

CONTEXT: Physicians who migrate globally face a daunting series of time-consuming, labor- and resource-intensive procedures to prove their clinical competency before being allowed to practice medicine in a new country. ISSUES: In this commentary, we describe licensing barriers faced by physician-migrants based on the authors' experiences, and reflect also on rapidly implemented measures to address COVID-19 pandemic related workforce shortages. We offer recommendations for potential reductions in bureaucratic regulatory barriers that prohibit mobilization of international medical graduate talent. LESSONS LEARNED: Licensing boards and authorities should strive for standardized, competency-based basic professional recognition. Professional medical societies are well-positioned to guide such competency-based recognition as a more organized, international collaborative effort across specialties. The COVID-19 pandemic facilitated cross-state and international licensing in some regions, highlighting a key opportunity: streamlining professional recognition requirements is achievable.

The Potential Impact of Scribes on Medical School Applicants and Medical Students with the New Clinical Documentation Guidelines.

The presence of scribes in various specialties, including internal medicine, is being heralded as a way to decrease clinician documentation time and burnout. Many medical school applicants become scribes to understand life as a doctor and gain clinical experience. Scribing is already perceived by some as a new key to successfully gaining entrance to medical school. One season of our admissions data showed that scribes were more likely to be admitted (OR = 1.61). Scribes may also inadvertently make it harder for medical schools to secure clinical placements for medical students. While trained scribes are highly valued by providers struggling to deal with increasing documentation burdens, supervising or training scribes also requires time that cannot be devoted to teaching. Medical documentation duties could provide valuable learning experiences for medical students. The recent ruling allowing medical students to contribute directly to clinical documentation without requiring redocumentation by supervisors gives medical schools and clinician-educators an opportunity to consider the unintended consequences of the scribe movement for medical education. Educators should consider when and how students can maximize the educational benefits of participating in patient documentation despite the templated methods commonly used in electronic health record (EHR) systems.

Effect of medical student preference on rural clinical school experience and rural career intentions.

INTRODUCTON: The key parameter for rural clinical schools (RCSs) is to provide at least 1 year of clinical training in rural areas for 25% of Australian Commonwealth supported medical students with the intent to influence future rural medical workforce outcomes. The objective of this study was to describe the association between a medical student's selection preference and their RCS experience and rural career intent. METHODS: Medical students completing an RCS placement in 2012 and 2013 were encouraged to complete a survey regarding their experience and future career intent. Data were analysed to compare medical students for whom the RCS was their first choice with students who described the RCS as other than their first preference. RESULTS: Students for whom RCS was their first choice (724/1092) were significantly more likely to be female, come from a rural background and be from an undergraduate program. These students reported more positive experiences of all aspects of the RCS program (costs, access, support and networks, safety) and were 2.36 times more likely to report intentions to practice in a non-metropolitan area (odds ratio(OR)=2.36 (95% confidence interval(CI)=1.82-3.06), p<0.001). This was true for students of rural (OR=3.11 (95%CI=1.93-5.02), p<0.001) and metropolitan backgrounds (OR=2.07 (95%CI=1.48-2.89), p<0.001). More students in the first-choice group (68.8%) intended to practice in a regional area (not a capital or major city), significantly higher than the 48.4% of participants in the other-preference group (χ2 (1) 42.79, p<0.001). CONCLUSIONS: The decision to choose an RCS placement is a marker of rural career intention and a positive rural training experience for students of both rural and metropolitan backgrounds. It may be important to identify other-preference students and their specific social support needs to ensure a positive perception of a future rural career.

Medical student satisfaction, coping and burnout in direct-entry versus graduate-entry programmes.

CONTEXT: There is ongoing debate regarding the optimal length of medical training, with concern about the cost of prolonged training. Two simultaneous tracks currently exist in Australia: direct entry from high school and graduate entry for students with a bachelor degree. Medical schools are switching to graduate entry based on maturity, academic preparedness and career-choice surety. We tested the assumption that graduate entry is better by exploring student preferences, coping, burnout, empathy and alcohol use. METHODS: From a potential pool of 2188 participants, enrolled at five Australian medical schools, a convenience sample of 688 (31%) first and second year students completed a survey in the middle of the academic year. Participants answered questions about demographics, satisfaction and coping and completed three validated instruments. RESULTS: Over 90% of students preferred their own entry-type, though more graduate-entry students were satisfied with their programme (82.4% versus 65.3%, p < 0.001). There was no difference between graduate-entry and direct-entry students in self-reported coping or in the proportion of students meeting criteria for burnout (50.7% versus 51.2%). Direct-entry students rated significantly higher for empathy (concern, p = 0.022; personal distress, p = 0.031). Graduate-entry students reported significantly more alcohol use and hazardous drinking (30.0% versus 22.8%; p = 0.017). CONCLUSIONS: Our multi-institution data confirm that students are generally satisfied with their choice of entry pathway and do not confirm significant psychosocial benefits of graduate entry. Overall, our data suggest that direct-entry students cope with the workload and psychosocial challenges of medical school, in the first 2 years, as well as graduate-entry students. Burnout and alcohol use should be addressed in both pathways. Despite studies showing similar academic outcomes, and higher total costs, more programmes in Australia are becoming graduate entry. Further research on non-cognitive issues and outcomes is needed so that universities, government funders and the medical profession can decide whether graduate entry, direct entry, or a mix, is ideal.

The Effect of Weight Loss on Indigenous Australians with Diabetes: a study of Feasibility, Acceptability and Effectiveness of Laparoscopic Adjustable Gastric Banding.

BACKGROUND/OBJECTIVES: Diabetes and obesity are common and serious health challenges for indigenous people worldwide. The feasibility of achieving substantial weight loss, leading to remission of diabetes, was evaluated in a regional indigenous Australian community. SUBJECTS/METHODS: A prospective cohort study of 30 obese indigenous adults from the Rumbalara Aboriginal Co-operative in Central Victoria was performed. Inclusion criteria included aboriginality, BMI > 30 kg/m(2) and diabetes diagnosed within the last 10 years. Weight loss was achieved using laparoscopic adjustable gastric banding (LAGB). Participants were treated in their community and followed for 2 years. Outcomes were compared with those of non-indigenous Australians from an earlier randomized controlled trial (RCT) using a similar protocol. RESULTS: 30 participants (26 females, mean age 44.6 years; mean BMI 44.3) had LAGB at the regional hospital. Twenty-six participants completed diabetes assessment at 2 years follow-up. They showed diabetes remission (fasting blood glucose < 7.0 mmol/L and haemoglobin A1c (HbA1c) < 6.2 % while off all therapy except metformin) in 20 of the 26 and a mean weight loss (SD) of 26.0 (14) kilograms. Based on intention-to-treat, remission rate was 66 %. Quality of life improved. There was one early event and 12 late adverse events. The outcomes for weight loss and diabetes remission were not different from the LAGB group of the RCT. CONCLUSIONS: For obese indigenous people with diabetes, a regionalized model of care centred on the LAGB is an effective approach to a serious health problem. The model proved feasible and acceptable to the indigenous people. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN 12609000319279).

Nonglycemic targets in diabetes.

In conclusion, targets for patients with diabetes have actually become simpler with the release of new guidelines. The targets discussed in this article are summarized in Box 3. Finally, as clinicians and patients with diabetes struggle with the overwhelming burden of care, clinicians should consider the increasingly codified ethic of minimally disruptive medicine, which considers not just what patients and doctors can do but what patients' priorities, wishes, and needs are rather than the many specialist tests and treatment options available. Finding the balance may be easier with the new evidence-based and more straightforward guidelines.

Rural origin plus a rural clinical school placement is a significant predictor of medical students' intentions to practice rurally: a multi-university study.

INTRODUCTION: Health workforce shortages are a major problem in rural areas. Australian medical schools have implemented a number of rural education and training interventions aimed at increasing medical graduates' willingness to work in rural areas. These initiatives include recruiting students from rural backgrounds, delivering training in rural areas, and providing all students with some rural exposure during their medical training. However there is little evidence regarding the impact of rural exposure versus rural origin on workforce outcomes. The aim of this study is to identify and assess factors affecting preference for future rural practice among medical students participating in the Australian Rural Clinical Schools (RCS) Program. METHODS: Questionnaires were distributed to 166 medical students who had completed their RCS term in 2006; 125 (75%) responded. Medical students were asked about their preferred location and specialty for future practice, their beliefs about rural work and life, and the impact of the RCS experience on their future rural training and practice preferences. RESULTS: Almost half the students (47%; n=58) self-reported a 'rural background'. Significantly, students from rural backgrounds were 10 times more likely to prefer to work in rural areas when compared with other students (p<0.001). For those preferring general practice, 80% (n=24) wished to do so rurally. Eighty-five per cent (n=105) of students agreed that their RCS experience increased their interest in rural training and practice with 62% (n=75) of students indicating a preference for rural internship/basic training after their RCS experience. A substantial percentage (86%; n=108) agreed they would consider rural practice after their RCS experience. CONCLUSIONS: This baseline study provides significant evidence to support rural medical recruitment and retention through education and training, with important insights into the factors affecting preference for future rural practice. By far the most significant predictor of rural practice intention is recruitment of students with a rural background who also undertake an RCS placement. This research also demonstrates significant demand for post-graduate rural training places, including specialty places, as RCS graduates become junior doctors and vocational trainees.

Physician's assistants: a workforce solution for Australia?

Significant medical workforce shortages, particularly in rural and remote locations, have prompted a range of responses in Australia at both state and Commonwealth levels. One such response was a pilot project to test the suitability of the Physician Assistant (PA) role in the Australian context. Five US-trained and accredited PAs were employed by Queensland Health and deployed in urban, rural and remote settings across Queensland. A concurrent mixed-method evaluation was conducted by Urbis, an independent research firm. The evaluation found that the PAs provided quality, safe clinical care under the supervision of local medical officers. The majority of nurses and doctors who worked with the PAs believed that the PAs made a positive contribution to the health care team by increasing capacity to meet patient needs; reducing on-call requirements for doctors; liaising with other clinical team members; streamlining procedures for efficient patient throughput; and providing continuity during periods of doctor changeover. The Pilot demonstrated that a delegated PA role can provide safe, quality health care by augmenting an established healthcare team. The PA role has the potential to benefit the community by increasing the capacity of the health care system, and to improve recruitment and retention by providing an additional professional pathway. The small size of the Pilot limits the ability to generalise regarding the future efficacy of the PA role in Australia. Further research is required to test training and deployment of PAs in a wider range of Australian clinical settings, including general practice and rural health clinics.

A multi-university evaluation of the rural clinical school experience of Australian medical students.

INTRODUCTION: Medical students have been attending rural clinical schools (RCSs) since 2001. Although there have been generally positive single institution reports, there has been no multi-institution study using a common survey instrument. The experiences of medical students who attended a number of RCSs during 2006 were evaluated using a rural-specific questionnaire. METHODS: Questionnaires were distributed to 166 medical students who had completed one year at the RCS of six participating universities across Australia, including the Universities of New South Wales, Melbourne, Tasmania, Adelaide, and Sydney, and the Australian National University, of whom 125 responded (75.3%). Students were asked to rate their level of agreement on 29 items concerning their overall RCS experience, skills development and clinical supervision experience. RESULTS: The majority of respondents (n = 107, 86%) stated they would go to the RCS again if they had their time over and almost two-thirds (n = 77, 64%) stated they would spend more time at the RCS if they could. All items evaluating the educational experience recorded greater than 80% agreement (indicating very positive perceptions of the RCS experience). For the items concerning skills development, the highest level of agreement related to developing procedural skills (n = 121, 97%). For items relating to clinical supervision the agreement rate exceeded 80%. The majority of students found supervisors approachable (n = 121, 97%), enthusiastic (n = 120, 96%) and respectful (n = 119, 95%). CONCLUSIONS: Students' experiences in the RCSs are unequivocally positive. Most importantly, the RCS environment was conducive to learning and the development of clinical skills, the students were able to see an adequate number of patients and were well-prepared for examinations, and their supervisors were very good and acted as positive role models. This augers well for the success of the RCS program and for its role in attracting future doctors to work in rural environments.

A multi-university study of which factors medical students consider when deciding to attend a rural clinical school in Australia.

INTRODUCTION: As in many developed nations, there is a shortage in the rural medical workforce in Australia. Research indicates that a strong relationship exists between rural educational exposure and an increased interest in pursuing a rural career or selecting a rural internship. Accordingly, in 2000 the Australian Commonwealth Government established the Rural Clinical Schools (RCS) program. Under this program, 25% of parent medical schools' Commonwealth Supported Place (CSP) medical students must spend at least 1 year of their clinical medical education in a rural setting. Research indicates that positive experiences are of vital importance in determining future rural practice. Arguably, if students are conscripted to a RCS, they may view their overall experience negatively. Thus, the development and sustainability of an adequate future rural medical workforce depends on medical schools understanding and fostering the factors that encourage voluntary student recruitment to the RCSs. The aim of the present study was to determine which factors Australian medical students consider in their decision to attend RCSs. METHODS: This study employed survey research. The questionnaire, which used a 6 point Likert scale, addressed factors influencing students' decision to attend an RCS, including whether these factors were viewed as positive or negative. Open-ended questions provided students with an opportunity to make comments about their decision-making. The setting was the RCSs of six participating Australian universities. The participants were medical students enrolled at one of six Australian universities in 2006 (n=166) who had completed their RCS term; 125 students responded (75% response rate). RESULTS: At least three-quarters of the respondents considered the following when deciding whether to attend an RCS: patient access, academic reputation, their friends, the availability of subsidized accommodation provided by the clinical school, extra-curricular activities, social opportunities and transport costs. The majority of students considered the following as positive considerations: 'patient access', 'academic reputation', and 'subsidized accommodation'. However, for other students these same factors were negative considerations. CONCLUSION: Students consider both clinical and non-clinical factors in their decision to attend an RCS. The primary positive factor in the present study was patient access with 97% students (n=119) considering this to be important, and 84% students (n=81) stating that this was a positive factor in their decision-making. The other major factors, friends and academic reputation, appear equally considered. However, they differed in the degree to which they were regarded as a positive or negative consideration. Identifying and promoting positive factors is essential if the future rural medical workforce is to be enhanced. This study supports the importance of RCSs not being over-crowded and, thus, maintaining patient access, and also the importance of institutions having sufficient resources to support an excellent academic reputation. Interestingly, and perhaps somewhat contrary to expectations, students of metropolitan origin appear to be increasingly attracted to RCSs. Although numerous studies show that rural origin is a strong predictor of rural medical workforce membership, urban students who attend an RCS and have a positive experience may also be open to future rural practice.