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BACKGROUND: Multimorbidity is a rising health care phenomenon and doctors require specific skill sets to effectively care for patients with multiple illnesses. Despite this, most medical education is taught using a single-disease, systems-based approach. Consequently, students can struggle to manage patients with multimorbidity. To help final year medical students manage patients with multimorbidity in clinical practice, we devised, taught, and evaluated a heuristic: collect, cluster and co-ordinate. APPROACH: Students attended a 1-hour online workshop during their family medicine clerkship. Using a flipped classroom design, students watched a podcast, followed by facilitated small-group work. EVALUATION: Out of 132 final-year medical students, 102 participated in the evaluation. Students rated their confidence managing patients with multimorbidity, pre and post teaching on a Likert scale. Prior to teaching, 36% (n = 37) students rated their ability to manage a patient with multimorbidity as slightly confident. After teaching, 74.5% (76) students rated their ability to manage the same patient as fairly or completely confident. Prior to graduation students were surveyed to determine if they had applied the framework during clinical placements. Sixty-one students responded; 32 applied the heuristic during family medicine and in other clinical rotations such as paediatrics, obstetrics, emergency medicine and anaesthesia. IMPLICATIONS: Specific instruction on managing consultations with patients experiencing multimorbidity during undergraduate medical education increased learner confidence caring for these patients. The heuristic was relevant and applied in disciplines outside family medicine. Students indicated that earlier teaching on this topic would have prepared them better for clinical placements.
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PURPOSE: Physicians often experience moral distress from being prevented from taking what they believe to be the right course of action. Although causes and consequences of moral distress have been studied, little research offers insight into the significance of feeling morally challenged, especially in medicine. This study was undertaken to advance understanding of what physicians experience when encountering morally challenging situations and to examine how those experiences influence their interactions with the world of health care. METHOD: Guided by hermeneutic phenomenology, the authors conducted semistructured interviews with purposefully sampled Canadian physicians from September 2022 to January 2023. Analysis used Van Manen's 6 activities of hermeneutic research and included "story crafting" to sharpen insights. Late in that process, Van Manen's "lived existentials" was determined to provide a strong framework for physicians' experiences of moral distress. RESULTS: Of the 12 physicians interviewed, all experienced varied and long-lasting emotional reactions to morally challenging experiences. The emotions associated with moral distress, reported as inevitable, were experienced in ways that aligned with the lived existentials of body, space, time, and relations. CONCLUSIONS: A richer understanding of physicians' lived experiences with moral distress can help mentors and educators more thoughtfully engage in conversations about it with colleagues and learners. This study highlights the core dimensions of moral distress through body, space, time, and relations, thereby providing a means to enrich discussion about emotions and their transformational power. Through such nuanced consideration, calls for emotional candor may be strengthened to enhance practice by acknowledging the scope of impact that efforts to deliver care are likely to provoke.
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PURPOSE: There is a shortage of generalist physicians globally impacting health equity and access to care. An important way in which medical schools can demonstrate social accountability is by graduating learners interested in careers in generalism. While generalism is endorsed as a matter of principle in medical education, how this translates into curricula is less clear. The aim of this study was to identify how generalism is understood and supported by family physician educational leaders in undergraduate medical education (UME) in Canada. METHODS: We conducted a qualitative study, interviewing 38 family medicine leaders in UME across all 17 Canadian medical schools. We examined the data with template analysis, informed by the iceberg model of systems thinking. RESULTS: Four themes were identified: (1) Teaching and learning strategies in support of generalism-a consistent range existed across UME curricula; (2) Curriculum patterns-changes in leadership and curriculum reform created positive or negative feedback loops that promoted or hindered initiatives to support generalism; (3) Curriculum structures-organ-system-based curricula and availability of generalist faculty presented particular challenges to teaching generalist approaches; (4) Mental models and ways of knowing-the preponderance of biomedical frameworks of thinking in curricula unconsciously undermined generalist approaches to patient care. CONCLUSIONS: UME programmes promoted generalism through a range of teaching activities and strategies, but these efforts were countered by curriculum structures and mental models that perpetuate epistemic inequity between biomedical approaches to medical education and generalist models of care. Novel curricular frameworks are needed to align undergraduate programmes' commitment to social accountability with community-based need.
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PURPOSE: Undergraduate medical education (UGME) has to prepare students to do safety-critical work (notably, to prescribe) immediately after qualifying. Despite hospitals depending on them, medical graduates consistently report feeling unprepared to prescribe and they sometimes harm patients. Research clarifying how to prepare students better could improve healthcare safety. Our aim was to explore how students experienced preparing for one of their commonest prescribing tasks: intravenous fluid therapy (IVFT). METHODS: Complexity assumptions guided the research, which used a qualitative methodology oriented towards hermeneutic phenomenology. The study design was an uncontrolled and unplanned complex intervention: judicial review of the iatrogenic death of five children due to hyponatraemia in our region had resulted in the recommendation that students' education in 'the implementation of important clinical guidelines' relevant to fluid and electrolyte balance should be intensified. An opportunity sample of 40 final-year medical students drew and gave audio-recorded commentaries on rich pictures. We completed two template analyses: one of participants' transcribed commentaries on the pictures and one using a novel heuristic to analyse the pictures themselves. We then reconciled the two analyses into a single template. RESULTS: There were four themes: affects, teaching and learning, contradictions, and the curriculum as a journey. To explore interconnections between themes, we chose the picture best exemplifying each of the four themes and interpreted the curriculum journey depicted in each of them. These interpretations were grounded in each participant's picture, verbal account of the picture, and the aggregate findings of the template analysis. Participants' experiences were influenced by the situated complexity of IVFT. Layered on top of that, contradictions, overlaps, and gaps within the curriculum introduced extraneous complexity. Confusion and apprehension resulted. CONCLUSIONS: After spending five years preparing to prescribe IVFT, participants felt unprepared to do so. We conclude that intensive teaching had not achieved its avowed goal of improving students' preparedness for safe practice. Merton's seminal work on the 'unanticipated consequences of purposive social action' suggests that intensive teaching may even have contributed to their unpreparedness.
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OBJECTIVES: This study reviewed existing recommendations for virtual mental healthcare services through the quadruple aim framework to create a set of recommendations on virtual healthcare delivery to guide the development of Canadian policies on virtual mental health services. DESIGN: We conducted a systematic rapid review with qualitative content analysis of data from included manuscripts. The quadruple aim framework, consisting of improving patient experience and provider satisfaction, reducing costs and enhancing population health, was used to analyse and organise findings. METHODS: Searches were conducted using seven databases from 1 January 2010 to 22 July 2022. We used qualitative content analysis to generate themes. RESULTS: The search yielded 40 articles. Most articles (85%) discussed enhancing patient experiences, 55% addressed provider experiences and population health, and 25% focused on cost reduction. Identified themes included: screen patients for appropriateness of virtual care; obtain emergency contact details; communicate transparently with patients; improve marginalised patients' access to care; support health equity for all patients; determine the cost-effectiveness of virtual care; inform patients of insurance coverage for virtual care services; increase provider training for virtual care and set professional boundaries between providers and patients. CONCLUSIONS: This rapid review identified important considerations that can be used to advance virtual care policy to support people living with mental health conditions in a high-income country.
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Atención a la Salud , Servicios de Salud Mental , Humanos , Países Desarrollados , Canadá , RentaRESUMEN
INTRODUCTION: Despite moves across medical education to increase learning of generalist principles, a lack of clarity about what generalism means and how we should train doctors as 'generalists', has remained. This study explores how international, undergraduate and postgraduate, policy and educational mission documents characterise the practice and learning of generalism and how this can inform physician training. METHODS: A narrative literature review was conducted based on policy and mission documents identified through grey literature searches and a wider systematic review looking at empirical texts. Texts published between 1999 and present and related to 'generalism' were eligible for inclusion. Texts were coded and codes were reviewed and grouped into key themes. RESULTS: Thirty-four documents were included. Definitions vary: some described generalism as a basic skill, whilst others emphasised expertise. Factors which support learning generalism include: favourable financial outcomes; ageing populations; coordination of multidisciplinary care; demand for doctors with transferable skills; and patient expectations. Barriers to learning about generalism include: preference for specialisation; structure of undergraduate teaching and assessment; and the hidden curriculum. Solutions may include re-imagining generalists and specialists as being on a continuum as well as increasing exposure throughout medical education. DISCUSSION: Whilst generalism is consistently positioned as valuable, less clarity exists about how best to operationalise this in medical education. Fundamental ideological and structural changes within teaching curricula and assessment, are necessary to improve generalist learning and to promote sustainable practice. Medical education needs careful, considered planning to ensure workforce expertise is meeting population needs.
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BACKGROUND: Most prescriptions for sedative-hypnotics are written by family physicians. Given the influence of preceptors on residents' prescribing, this study explored how family physician preceptors manage sleeping problems. METHODS: Family physician preceptors affiliated with a postgraduate training program in Alberta were invited to participate in this mixed-methods study, conducted from January to October 2021. It included a quantitative survey of preceptors' attitudes to treatment options for sleep disorder, perceptions of patient expectations and self-efficacy beliefs. Participants indicated their responses on a 5-point Likert scale ranging from "strongly disagree" to "strongly agree." Respondents were then asked whether they were interested in participating in a semistructured qualitative interview that elicited preceptors' management of sleep disorder in response to a series of vignettes. We analyzed the quantitative data using descriptive statistics and the qualitative interviews using thematic analysis. RESULTS: Of the 76 preceptors invited to participate, 47 (62%) completed the survey, and 10 were interviewed. Thirty-two survey respondents (68%) were in academic teaching clinics, and 15 (32%) were from community clinics. The majority of participants (34 [72%]) agreed they had sufficient expertise to use nondrug treatment. Most (43 [91%]) had made efforts to reduce prescribing, and 45 (96%) felt able to support patients empathically when not using sleeping medication. The qualitative data showed that management of sleeping disorder was emotionally challenging. Participants hesitated to prescribe sedatives and reported "exceptions" to prescribing, many of which included indications within guideline recommendations. Participants were reluctant to change a colleague's management. INTERPRETATION: Preceptors were confident using nonpharmacologic management to treat sleep disorder and hesitant to use sedative-hypnotics, presenting legitimate use of sedatives as exceptional behaviour. Acknowledging social norms and affective aspects involved in prescribing may support balanced prescribing of sedative-hypnotics for sleep disorder and reduce physician anxiety.
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Background: Family physicians are uniquely able to provide comprehensive and longitudinal care to those experiencing sexual assault and domestic violence (SADV). To date, we know little about how Canadian family medicine (FM) residents learn about SADV. This study explored SADV teaching in residency from the perspectives of FM residents. Methods: This qualitative study took place in the Western University FM residency program. We conducted semi-structured interviews with first- and second-year FM residents (n = 8). We analyzed data using thematic analysis. Results: We identified three inter-related themes: (1) Inconsistent training for SADV, (2) Attitudes towards SADV and (3) Learner hesitancy. Quality and quantity of SADV learning opportunities were inconsistent across learners, fuelling feelings of incompetence and lack of confidence around providing SADV care.This led to hesitant behaviours by learners when encountering SADV clinically. Conclusions: Understanding FM residents' experiences and ideas regarding SADV education is critical in order to graduate physicians equipped to care for this vulnerable population. This research highlights the relationship among learners' and teachers' experiences, attitudes and behaviours; targeting this behavioural cycle may improve SADV learning.
Contexte: Les médecins de famille sont particulièrement bien places pour fournir des soins complets et longitudinaux aux personnes victimes d'agression sexuelle et de violence familiale (ASVF). À ce jour,nous savons peu de choses sur la façon dont les résidents en medicine familiale (MF) au Canada se familiarisent avec l'ASVF. Cette etude explore la formation sur le sujet dans le cadre de la résidence en MF,du point de vue des résidents eux-mêmes. Méthodes: Cette étude qualitative s'est déroulée dans le cadre du programme de résidence en FM de l'Université Western. Nous avons mené des entretiens semi-structurés avec des résidents en première et deuxième année de médecine familiale (n=8). Les données ont fait l'objet d'une analyse thématique. Résultats: Nous avons relevé trois thèmes interdépendants : (1) Formation inégale en matière d'ASVF, (2) Attitudes envers l'ASVF et (3) Hésitation de la part des apprenants. La qualité et la quantité des occasions d'apprentissage sur le sujet de l'ASVF n'étaient pas uniformes parmi les apprenants, alimentant des sentiments d'incompétence et un manque de confiance dans la prestation de soins liés à l'ASVF. En conséquence, les apprenants sont hésitants lorsqu'ils rencontrent des situations liées à l'ASVF en clinique. Conclusions: Il est essentiel de comprendre les expériences et les idées des résidents en MF concernant la formation sur le sujet de l'ASVF afin de former des médecins qui seront outillés pour s'occuper d'une population vulnérable. Nos travaux mettent en évidence la relation entre les expériences, les attitudes et les comportements des apprenants et des enseignants. On peut améliorer l'apprentissage en matière d'ASVF en ciblant ce cycle comportemental.
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Violencia Doméstica , Delitos Sexuales , Humanos , Medicina Familiar y Comunitaria , Canadá , Aprendizaje , Médicos de FamiliaRESUMEN
BACKGROUND: Training clinicians on the use of hospital-based patient monitoring systems (PMS) is vital to mitigate the risk of use errors and of frustration using these devices, especially when used in ICU settings. PMS training is typically delivered through face-to-face training sessions in the hospital. However, it is not always feasible to deliver training in this format to all clinical staff given some constraints (e.g., availability of staff and trainers to attend in-person training sessions and the costs associated with face-to-face training). OBJECTIVE: The literature indicates that E-learning has the potential to mitigate barriers associated with time restrictions for trainers and trainees and evidence shows it to be more flexible, and convenient for learners in healthcare settings. This study aimed to develop and carry out a preliminary evaluation via a case study of an e-learning training platform designed for a novel neonatal sepsis risk monitor system (Digi-NewB). METHODS: A multi-modal qualitative research case study approach was used, including the analysis of three qualitative data sources: (i) audio/video recordings of simulation sessions in which participants were asked to operate the system as intended (e.g., update the clinical observations and monitor the sepsis risk), (ii) interviews with the simulation participants and an attending key opinion leader (KOL), who observed all simulation sessions, and (iii) post-simulation survey. RESULTS: After receiving ethical approval for the study, nine neonatal intensive care unit (NICU) nurses completed the online training and participated in the simulation and follow-up interview sessions. The KOL was also interviewed, and seven out of the nine NICU nurses answered the post-simulation survey. The video/audio analysis of the simulations revealed that participants were able to use and interpret the Digi-NewB interface. Interviews with simulation participants and the KOL, and feedback extracted from the survey, revealed that participants were overall satisfied with the training platform and perceived it as an efficient and effective method to deliver medical device training. CONCLUSIONS: This study developed an online training platform to train clinicians in the use of a critical care medical device and carried out a preliminary evaluation of the platform via a case study. The e-learning platform was designed to supplement and enhance other training approaches. Further research is required to evaluate the effectiveness of this approach.
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Instrucción por Computador , Sepsis Neonatal , Recién Nacido , Humanos , Aprendizaje , Encuestas y Cuestionarios , Unidades de Cuidados IntensivosRESUMEN
BACKGROUND: There is a pressing need for healthcare to respond to the climate crisis. Family physicians, given their central role in community healthcare provision, are strategically placed to lead, support, and promote sustainable healthcare, yet guidance on how to do this is fragmented. OBJECTIVE: To identify and evaluate toolkits and aids on sustainable healthcare to act as a curated resource for family physicians and their care teams interested in delivering evidence-based sustainable healthcare in their clinical practices. METHODS: A scoping review was completed of the published and grey literature across 4 databases and 2 search engines to identify articles and aids/toolkits from 1990 to present. Toolkits were subsequently evaluated for purpose, evidence-base, implementation process, adaptability to family medicine, and outcome measures. RESULTS: The search identified 17,751 articles. Screening resulted in 20 published articles and 11 toolkits. Most articles presented simple checklists to support greening clinic initiatives, 3 studies focussed on partial carbon footprint analyses, and 4 on educational initiatives. Toolkits ranged in sustainability topics and degree of depth covered, and adaptability and outcome measures. None of the resources identified have been formally evaluated for effectiveness. CONCLUSIONS: A range of aids exist to support greening of clinic operations; however, there is a significant gap in the literature for greening clinical care. Two toolkits were found to be comprehensive, one requiring tracking and reporting of sustainability initiatives. This scoping review provides a starting point for motivated family doctors and community clinics to initiate change and support more sustainable healthcare.
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Instituciones de Atención Ambulatoria , Medicina Familiar y Comunitaria , Humanos , Servicios de Salud Comunitaria , EscolaridadRESUMEN
This article suggests communicative steps and strategies to help healthcare professionals achieve the ideals of child-centred care, which place children and young people at the centre of policy and practice. For those with 15 s, not 15 min, our suggestions can be summarised like this: help children be active agents in their own care by asking, listening well, being curious and explaining things clearly in an accessible but not condescending way.
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Salud Infantil , Derivación y Consulta , Humanos , Niño , Adolescente , Comunicación , Personal de SaludRESUMEN
INTRODUCTION: Serological SARS-CoV-2 assays have an important role in guiding the pandemic response. This research aimed to compare the performance of 2 antinucleocapsid assays. METHODS: Serum from 49 HCWs was analysed at baseline and 6 months using the Abbott diagnostics SARS-CoV-2 IgG assay and the Roche Diagnostics Elecsys Anti-SARS-CoV-2 total antibody assay. RESULTS: At baseline, 14/49 participants (29%) demonstrated antibody reactivity using the Abbott assay. At 6 months, 4/14 participants (29%) continued to demonstrate reactivity. A total of 14/49 (29%) participants had detectable antibodies at baseline using the Roche assay. In total, 13/14 (93%) of participants demonstrated antibody reactivity at 6 months. The Abbott assay showed a statistically significant difference in the signal-to-threshold values of baseline reactive samples when repeated at 6 months (p = 0.001). This was not seen with the Roche assay (p = 0.51). CONCLUSION: In this small study, the Roche Diagnostics Elecsys Anti-SARS-CoV-2 total antibody assay appears superior in performance to the Abbott diagnostics SARS-CoV-2 IgG assay in accurately detecting participants with a history of confirmed COVID-19 disease at 6 months follow-up. This finding should be born in mind in the planning of future seroprevalence studies, especially when considering the use of anti-nucleocapsid assays.
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COVID-19 , SARS-CoV-2 , Anticuerpos Antivirales , COVID-19/diagnóstico , Personal de Salud , Humanos , Inmunoglobulina G , Sensibilidad y Especificidad , Estudios SeroepidemiológicosRESUMEN
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies are an excellent indicator of past COVID-19 infection. As the COVID-19 pandemic progresses, retained sensitivity over time is an important quality in an antibody assay that is to be used for the purpose of population seroprevalence studies. We compared 5,788 health care worker (HCW) serum samples by using two serological assays (Abbott SARS-CoV-2 anti-nucleocapsid immunoglobulin G (IgG) and Roche anti-SARS-CoV-2 anti-nucleocapsid total antibody) and a subset of samples (all Abbott assay positive or grayzone, n = 485) on Wantai SARS-CoV-2 anti-spike antibody enzyme-linked immunosorbent assay (ELISA). For 367 samples from HCW with a previous PCR-confirmed SARS-CoV-2 infection, we correlated the timing of infection with assay results. Overall, seroprevalence was 4.2% on Abbott and 9.5% on Roche. Of those with previously confirmed infection, 41% (150/367) and 95% (348/367) tested positive on Abbott and Roche, respectively. At 21 weeks (150 days) after confirmed infection, positivity on Abbott started to decline. Roche positivity was retained for the entire study period (33 weeks). Factors associated (P ≤ 0.050) with Abbott seronegativity in those with previous PCR-confirmed infection included sex (odds ratio [OR], 0.30 male ; 95% confidence interval [CI], 0.15 to 0.60), symptom severity (OR 0.19 severe symptoms; 95% CI, 0.05 to 0.61), ethnicity (OR, 0.28 Asian ethnicity; 95% CI, 0.12 to 0.60), and time since PCR diagnosis (OR, 2.06 for infection 6 months previously; 95% CI, 1.01 to 4.30). Wantai detected all previously confirmed infections. In our population, Roche detected antibodies up to at least 7 months after natural infection with SARS-CoV-2. This finding indicates that the Roche total antibody assay is better suited than Abbott IgG assay to population-based studies. Wantai demonstrated high sensitivity, but sample selection was biased. The relationship between serological response and functional immunity to SARS-CoV-2 infection needs to be delineated. IMPORTANCE As the COVID-19 pandemic progresses, retained sensitivity over time is an important quality in an antibody assay that is to be used for the purpose of population seroprevalence studies. There is a relative paucity of published literature in this field to help guide public health specialists when planning seroprevalence studies. In this study, we compared results of 5,788 health care worker blood samples tested by using two assays (Roche and Elecsys, anti-nucleocapsid antibody) and by testing a subset on a third assay (Wantai enzyme-linked immunosorbent assay [ELISA] anti-spike antibody). We found significant differences in the performance of these assays, especially with distance in time from PCR-confirmed COVID-19 infection, and we feel these results may significantly impact the choice of assay for others conducting similar studies.
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Anticuerpos Antivirales/sangre , Prueba Serológica para COVID-19/métodos , COVID-19/diagnóstico , Proteínas de la Nucleocápside de Coronavirus/inmunología , SARS-CoV-2/inmunología , Glicoproteína de la Espiga del Coronavirus/inmunología , Adulto , Estudios Transversales , Ensayo de Inmunoadsorción Enzimática , Femenino , Personal de Salud/estadística & datos numéricos , Humanos , Inmunoglobulina G/sangre , Masculino , Persona de Mediana Edad , Fosfoproteínas/inmunología , Sensibilidad y Especificidad , Estudios Seroepidemiológicos , Adulto JovenRESUMEN
Qualitative inquiry is increasingly popular in health professions education, and there has been a move to solidify processes of analysis to demystify the practice and increase rigour. Whilst important, being bound too heavily by methodological processes potentially represses the imaginative creativity of qualitative expression and interpretation-traditional cornerstones of the approach. Rigid adherence to analytic steps risks leaving no time or space for moments of 'wonder' or emotional responses which facilitate rich engagement. Poetic inquiry, defined as research which uses poetry 'as, in, [or] for inquiry', offers ways to encourage creativity and deep engagement with qualitative data within health professions education. Poetic inquiry attends carefully to participant language, can deepen researcher reflexivity, may increase the emotive impact of research, and promotes an efficiency of qualitative expression through the use of 'razor sharp' language. This A Qualitative Space paper introduces the approach by outlining how it may be applied to inquiry within health professions education. Approaches to engaging with poetic inquiry are discussed and illustrated using examples from the field's scholarship. Finally, recommendations for interested researchers on how to engage with poetic inquiry are made, including suggestions as to how to poetize existing qualitative research practices.
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Creatividad , Empleos en Salud , Empleos en Salud/educación , Humanos , Investigación Cualitativa , InvestigadoresRESUMEN
OBJECTIVE: Explore children's and adolescents' (CADs') lived experiences of healthcare professionals (HCPs). DESIGN: Scoping review methodology provided a six-step framework to, first, identify and organise existing evidence. Interpretive phenomenology provided methodological principles for, second, an interpretive synthesis of the life worlds of CADs receiving healthcare, as represented by verbatim accounts of their experiences. DATA SOURCES: Five key databases (Ovid Medline, Embase, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and Web of Science), from inception through to January 2019, reference lists, and opportunistically identified publications. ELIGIBILITY CRITERIA: Research articles containing direct first-person quotations by CADs (aged 0-18 years inclusive) describing how they experienced HCPs. DATA EXTRACTION AND SYNTHESIS: Tabulation of study characteristics, contextual information, and verbatim extraction of all 'relevant' (as defined above) direct quotations. Analysis of basic scope of the evidence base. The research team worked reflexively and collaboratively to interpret the qualitative data and construct a synthesis of children's experiences. To consolidate and elaborate the interpretation, we held two focus groups with inpatient CADs in a children's hospital. RESULTS: 669 quotations from 99 studies described CADs' experiences of HCPs. Favourable experiences were of forming trusting relationships and being involved in healthcare discussions and decisions; less favourable experiences were of not relating to or being unable to trust HCPs and/or being excluded from conversations about them. HCPs fostered trusting relationships by being personable, wise, sincere and relatable. HCPs made CADs feel involved by including them in conversations, explaining medical information, and listening to CADs' wider needs and preferences. CONCLUSION: These findings strengthen the case for making CADs partners in healthcare despite their youth. We propose that a criterion for high-quality child-centred healthcare should be that HCPs communicate in ways that engender trust and involvement.