Capital sharing and socialization in an interprofessional student-led clinic: a Bourdieuan analysis.

BACKGROUND: Interprofessional student-led clinics offer authentic clinical experiences of collaborative patient care. However, theoretical research on the sustainability of these clinics, considering forms of capital beyond the economic, remains limited. This study addresses this gap by employing Bourdieu's theoretical framework to explore how alternative conceptions of capital; both social and cultural might sustain conditions for interprofessional working in a student-led clinic serving patients living with a chronic neurological impairment. METHODS: The teaching and learning focussed clinic was established in 2018 to mirror a clinical service. Semi-structured focus groups with participants involving 20 students from 5 professions and 11 patients gathered in-depth insights into their experiences within the clinic. A thematic analysis was guided by Bourdieu's concepts of field, habitus, and capital. RESULTS: In the complex landscape of the student-led clinic, at the intersection of a patient support group, a hospital-based aged care facility, and university-based healthcare professions, three pivotal mechanisms emerged underpinning its sustainability: Fostering students' disposition to interprofessional care, Capitalizing on collaboration and patient empowerment, and a Culture of mutual exchange of capital. These themes illustrate how students and patients specific dispositions towards interprofessional healthcare enriched their habitus by focusing on shared patient well-being goals. Diverse forms of capital exchanged by students and patients fostered trust, respect, and mutual empowerment, enhancing the clinic experience. CONCLUSION: This study bridges an important gap in theoretically informed explorations of the conditions for sustaining student-led clinics, drawing on Bourdieu's theory. It accentuates the significance of investment of diverse forms of capital in such clinics beyond the economic, whilst emphasizing a primary commitment to advancing interprofessional healthcare expertise. Recognizing patients as equal partners shapes clinic dynamics. In order for student clinics to thrive in a sustainable fashion, educators must shift their focus beyond solely maximizing financial resources. Instead, they should champion investments in a wider range of capital forms. This requires active participation from all stakeholders; faculties, patient partners, service providers, and students. These findings underscore the importance of investing in interprofessional learning by optimizing various forms of capital, and embracing patients as dynamic contributors to the clinic's sustainability.

Using cultural historical activity theory to reflect on the sociocultural complexities in OSCE examiners' judgements.

Examiners' judgements play a critical role in competency-based assessments such as objective structured clinical examinations (OSCEs). The standardised nature of OSCEs and their alignment with regulatory accountability assure their wide use as high-stakes assessment in medical education. Research into examiner behaviours has predominantly explored the desirable psychometric characteristics of OSCEs, or investigated examiners' judgements from a cognitive rather than a sociocultural perspective. This study applies cultural historical activity theory (CHAT) to address this gap in exploring examiners' judgements in a high-stakes OSCE. Based on the idea that OSCE examiners' judgements are socially constructed and mediated by their clinical roles, the objective was to explore the sociocultural factors that influenced examiners' judgements of student competence and use the findings to inform examiner training to enhance assessment practice. Seventeen semi-structured interviews were conducted with examiners who assessed medical student competence in progressing to the next stage of training in a large-scale OSCE at one Australian university. The initial thematic analysis provided a basis for applying CHAT iteratively to explore the sociocultural factors and, specifically, the contradictions created by interactions between different elements such as examiners and rules, thus highlighting the factors influencing examiners' judgements. The findings indicated four key factors that influenced examiners' judgements: examiners' contrasting beliefs about the purpose of the OSCE; their varying perceptions of the marking criteria; divergent expectations of student competence; and idiosyncratic judgement practices. These factors were interrelated with the activity systems of the medical school's assessment practices and the examiners' clinical work contexts. Contradictions were identified through the guiding principles of multi-voicedness and historicity. The exploration of the sociocultural factors that may influence the consistency of examiners' judgements was facilitated by applying CHAT as an analytical framework. Reflecting upon these factors at organisational and system levels generated insights for creating fit-for-purpose examiner training to enhance assessment practice.

Acute carpal tunnel syndrome from thrombosed persistent median artery in a patient with congenitally absent radial artery.

OBJECTIVES: Thrombosis of the persistent median artery (PMA) is a rare cause of acute carpal tunnel syndrome (ACTS). Existence of a congenitally absent radial artery in this setting has not been described in the literature. METHODS: Computed Tomography Angiography (CTA) and doppler screening were used in pre surgical planning. Open surgical decompression was achieved through the release of the flexor retinaculum in the left hand. A regimen of 100 mg of Aspirin for 3 months time was initiated to encourage clot resolution and recanalization of the thrombosed artery. RESULTS: The PMA was found to be abnormally large measuring approximately 4 mm in diameter. Visible clotting off of the PMA in keeping with the doppler scans with maintenance of distal flow and was left intact with the hopes that it would recanalize over time. At the 3-month post-op review the antiplatelet therapy was ceased and the patient was symptom free, demonstrated no signs of ischaemia in the hand, and had returned to full functionality and physical activity. CONCLUSIONS: Although infrequently encountered, the knowledge of the anatomical variations of the forearm and hand together with doppler screening and CTA is essential to the surgical management of ACTS.

Situated learning in community environments (SLICE): Systems design of an immersive and integrated curriculum for community-based learning.

PURPOSE: We sought to design a micro-curriculum to structure supervised clinical placements for junior medical students within a variety of community-based settings of differing clinical disciplines. Given the gaps in the literature, this paper reflects on the opportunities and challenges of our design, implementation, and evaluation strategies in constructing an integrated task-based micro-curriculum for interprofessional community-based learning in year 2 of a four-year graduate entry program. METHODS: The design was informed by a systems thinking framework and guided by contemporary curricular theories on self-directed and interprofessional learning. Extensive consultations with stakeholders were undertaken. Alignment with relevant national level documents and curricular frameworks was ensured. RESULTS: The systems thinking approach provided first, an experience of applying thinking tools for a deeper understanding of how various parts of this micro-curriculum and subsystems should be integrated. Second, applying the toolkit uncovered tension points on which leverage could optimise future enhancements. Eighteen types of health professions were recruited including 105 general practitioners and 253 healthcare practitioners from a range of disciplines. CONCLUSION: Systems thinking allows for the identification of various interacting elements within the curriculum to be considered as part of an integrated whole. Insights from this model could inform the design of similar innovative curricula.

Union and Complication Rates After Total Wrist Arthrodesis: A Systematic Review and Meta-Analysis.

PURPOSE: Total wrist arthrodesis (TWA) has been performed using various techniques. We aimed to provide pooled prevalence estimates of union and complications of TWA by technique. A secondary aim was to provide estimates of union and complication rates by treatment of the carpometacarpal joint (CMCJ) in TWA using plates. Given the widespread adoption of wrist arthrodesis plates (WAP), we hypothesized that these implants would result in higher union and lower complication rates. We also hypothesized that TWA with CMCJ arthrodesis would improve these outcomes. METHODS: Online databases including PubMed, Medline, Embase, and Cochrane were searched. Studies reporting union and/or complication rates of 10 or more TWA performed with a similar technique (analyzed as bone graft only, bone graft with minimal fixation, intramedullary, augmented intramedullary, plate, WAP, and other) were included. Studies with fewer than 10 TWA, studies reporting TWA where union or complications could not be analyzed separately, and studies without union and complication rates were excluded. Data extraction was performed independently by two English-speaking reviewers with a translator where required. Pooled prevalence estimates were made using a random-effects meta-analysis model and presented as a percent prevalence with 95% confidence and prediction intervals. RESULTS: One hundred and thirty-six studies with a total of 3,517 patients and 3,969 TWA were analyzed. No differences in union and complication prevalence were observed between TWA techniques and in TWA with different treatments of the CMCJ using plates and WAP. CONCLUSION: Using meta-analysis, we found no difference in union and complication prevalence between TWA techniques and TWA with different treatments of the CMCJ with plates and WAP. It must be acknowledged that this research included low-quality studies with high heterogeneity, and confidence in the precision of the estimates is low. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

MeCP2 Is an Epigenetic Factor That Links DNA Methylation with Brain Metabolism.

DNA methylation, one of the most well-studied epigenetic modifications, is involved in a wide spectrum of biological processes. Epigenetic mechanisms control cellular morphology and function. Such regulatory mechanisms involve histone modifications, chromatin remodeling, DNA methylation, non-coding regulatory RNA molecules, and RNA modifications. One of the most well-studied epigenetic modifications is DNA methylation that plays key roles in development, health, and disease. Our brain is probably the most complex part of our body, with a high level of DNA methylation. A key protein that binds to different types of methylated DNA in the brain is the methyl-CpG binding protein 2 (MeCP2). MeCP2 acts in a dose-dependent manner and its abnormally high or low expression level, deregulation, and/or genetic mutations lead to neurodevelopmental disorders and aberrant brain function. Recently, some of MeCP2-associated neurodevelopmental disorders have emerged as neurometabolic disorders, suggesting a role for MeCP2 in brain metabolism. Of note, MECP2 loss-of-function mutation in Rett Syndrome is reported to cause impairment of glucose and cholesterol metabolism in human patients and/or mouse models of disease. The purpose of this review is to outline the metabolic abnormalities in MeCP2-associated neurodevelopmental disorders that currently have no available cure. We aim to provide an updated overview into the role of metabolic defects associated with MeCP2-mediated cellular function for consideration of future therapeutic strategies.

Student perspectives on programmatic assessment in a large medical programme: A critical realist analysis.

BACKGROUND: Fundamental challenges exist in researching complex changes of assessment practice from traditional objective-focused 'assessments of learning' towards programmatic 'assessment for learning'. The latter emphasise both the subjective and social in collective judgements of student progress. Our context was a purposively designed programmatic assessment system implemented in the first year of a new graduate entry curriculum. We applied critical realist perspectives to unpack the underlying causes (mechanisms) that explained student experiences of programmatic assessment, to optimise assessment practice for future iterations. METHODS: Data came from 14 in-depth focus groups (N = 112/261 students). We applied a critical realist lens drawn from Bhasker's three domains of reality (the actual, empirical and real) and Archer's concept of structure and agency to understand the student experience of programmatic assessment. Analysis involved induction (pattern identification), abduction (theoretical interpretation) and retroduction (causal explanation). RESULTS: As a complex educational and social change, the assessment structures and culture systems within programmatic assessment provided conditions (constraints and enablements) and conditioning (acceptance or rejection of new 'non-traditional' assessment processes) for the actions of agents (students) to exercise their learning choices. The emergent underlying mechanism that most influenced students' experience of programmatic assessment was one of balancing the complex relationships between learner agency, assessment structures and the cultural system. CONCLUSIONS: Our study adds to debates on programmatic assessment by emphasising how the achievement of balance between learner agency, structure and culture suggests strategies to underpin sustained changes (elaboration) in assessment practice. These include; faculty and student learning development to promote collective reflexivity and agency, optimising assessment structures by enhancing integration of theory with practice, and changing learning culture by both enhancing existing and developing new social structures between faculty and the student body to gain acceptance and trust related to the new norms, beliefs and behaviours in assessing for and of learning.

Engaging clinical examiners with structured feedback to enhance assessment practices.

INTRODUCTION: Examiners' professional judgements of student performance are pivotal to making high-stakes decisions to ensure graduating medical students are competent to practise. Clinicians play a key role in assessment in medical education. They are qualified in their clinical area but may require support to further develop their understanding of assessment practices. However, there are limited studies on providing examiners with structured feedback on their assessment practices for professional development purposes. METHODS: This study adopts an interpretive paradigm to develop an understanding of clinical examiners' interpretations of receiving structured feedback and its impacts on enhancing their assessment literacy and practice. Data were collected from 29 interviews with clinical examiners who assessed the final-year medical objective structured clinical examinations (OSCEs) at one university. RESULTS: Inductive thematic analysis of these data revealed that the examiners considered the feedback to be useful with practical functions in facilitating communication, comparisons and self-reflection. However, the examiners' level of confidence in the appropriateness of their assessment practices and difficulties in interpreting feedback could be barriers to adopting better practices. CONCLUSION: Feedback for examiners needs to be practical, targeted, and relevant to support them making accountable and defensible judgements of student performance.

Interprofessional student-led clinics: the volunteer patient experience.

BACKGROUND: Learning from patients and gaining an understanding of their lived experience plays an important role in improving health professions education. However, opportunities for students to engage in interprofessional learning activities involving patients as partners remain limited. In 2018, we developed an interprofessional student-led clinic where people living with Parkinson's Disease voluntarily participated as 'patient-partners'. The aim of this pilot study was to explore patients' experience and motivation for participation. METHODS: In 2018 the clinic was implemented five times. Four patient volunteers and six to eight students from a mix of disciplines attended each clinic. Qualitative data were collected via semi-structured focus groups with patients. Data were analysed using thematic analysis. RESULTS: Eleven patients participated in the focus groups. Patients found the interprofessional nature of the clinic beneficial to their health goals. Their interactions with students from different disciplines helped to build their healthcare knowledge and confidence to ask additional questions of health professionals. Patients felt they offered unique perspectives to students of their own lived experiences. They found sharing their stories with students and each other built a sense of community. CONCLUSION: Patients felt they enriched the learning environment, helping students to build their knowledge and skills by providing authentic patient perspectives. The interprofessional aspect enhanced the patient experience in a number of ways. Patients found the multiple perspectives of healthcare helped them to build their own knowledge, and reflect on their changing needs. Warranting further investigation, our findings indicate that participation in the clinics may have positively influenced patients' health seeking behaviours.

Contextualised reflective competence: a new learning model promoting reflective practice for clinical training.

BACKGROUND: Reflection is a metacognitive process that allows self-regulation and the promotion of lifelong learning, and is an essential requirement to develop therapeutic relationships with patients and colleagues, as well as professional expertise. The medical literature is lacking on guidance for learners and educators to develop reflective abilities. METHODS: Based on our program of research into junior doctors delivering open disclosure communication after medical error, we developed a framework called contextualised reflective competence, to assist students/trainees and educators in developing, maintaining, and ensuring reflective practice in the context of professional experiences. RESULTS: The contextualised reflective competence framework has its origins in the conscious competency framework, an established learning paradigm within healthcare professions education, and it has been developed to encompass some of the vital concepts that the conscious competency matrix was lacking: the promotion of ongoing reflection practice, accurate assumptions of the learner's original mindset, variations in everyday performance, and erosion of skills. The contextualised reflective competence framework progresses the conscious competence framework from a 2x2 box diagram to a two-pronged flowchart. In our framework, if the learner possesses appropriate reflective practice, contextualised reflective competence, they move through alearning process where they achieve unconscious competence. If the learner does not possess contextualised reflective competence, they move though a learning process where this display generalised reflective incompetence, characterised by cognitive dissonance and rationalisation, leading to errors and non-learning. Generalised reflective incompetence is usually a temporary state with appropriate supervision. Our program of research demonstrated that contextualised reflective competence was related to critical cognitive frameworks, such as intellectual humility, situational awareness, the development of a 'growth mindset', and belongingness. CONCLUSIONS: The Contextualised Reflective Competence framework promotes learners' understanding of their core competencies and provides opportunities for personal critical reflection. It provides educators and supervisors with a diagnostic pathway for those with reflective incompetence. We anticipate its use in the clinical environment where issues of competence are raised in professional experiences.

Leadership behaviours in interprofessional student teamwork.

BACKGROUND: Effective leaders support high-quality patient care and improve patient safety by embodying a collective leadership style. Training in leadership skills needs to be integrated longitudinally throughout a clinician's career. Models of leadership drawn from organisational theories can provide a conceptual framework for cultivating student leadership qualities during teamwork and the evaluation of emergent outcomes. Using the conceptual framework of Situational Leadership Theory, we sought to explore the leadership qualities identified by students of their team members, during a large scale interprofessional learning activity. METHODS: In 2018, 1674 students from 11 health disciplines were required to participate in the "Health Collaboration Challenge" (HCC). The HCC required students to work in small interprofessional teams of five or six students. Following team activities, students were required to provide constructive written feedback to their team members. Peer feedback data were coded and categorised into themes using the conceptual framework of Situational Leadership Theory. Data were then quantified within each theme. RESULTS: A total of 1282 comments were analysed. The most frequent comments related to 'delegating' (456/1282, 36%) and 'supporting' (402/1282, 31%). This was followed by comments categorised as 'directing' (244/1282, 19%), and 'coaching' (180/1282, 14%) leadership styles. Notably, a total of 1112/2597 (43%) of comments were unconstructive. A total of 298 comments provided by students informed their peers of areas for self-improvement. The most frequent comments were recommendations relating to 'active team member contribution' (111/298; 37%), followed by 'communication' (83/298; 28%), 'interprofessional practice' (77/298; 26%), and 'disciplinary knowledge' (27/298; 9%). CONCLUSION: Although most students demonstrated a reasonable ability to display leadership behaviours appropriate to teamwork, further development is needed through training. Leadership skills are an expectation of health professional graduates, and should be explicitly taught and vertically integrated within interprofessional education curricula. Further research is warranted in how students contribute to and understand the requirements of leadership within interprofessional teams.

Student Interprofessional Facilitator Training (SIFT) program: building capacity in clinical education leadership.

BACKGROUND: While there are many teacher training programs for health professional students, few are interprofessional, and few integrate assessment and feedback prior to participation as peer teachers. In 2021, The Student Interprofessional Facilitator Training (SIFT) program was developed to allow senior students, already trained in peer teaching, to revise, build on, and practice their newly acquired skills in an interprofessional context. The aim of this study was to explore participant perception and performance, and the contextual factors that influence student aspirations as clinical teachers. METHODS: Alumni of the 2021 Peer Teacher Training program (n = 74) were invited to participate in the SIFT program. Those who participated were invited to attend individual semi-structured interviews. Thematic analysis was used to code and categorise data into themes, using Communities of Practice as a conceptual framework. Skills in interprofessional facilitation were observed, assessed and students were provided with individual feedback. Assessment data were analysed using descriptive statistics. RESULTS: Sixteen students from six disciplines joined the SIFT program, and 13/16 (81%) completed. Students were from medicine, nursing, diagnostic radiography, medical imaging, dentistry and speech pathology. Students reported an increased recognition of teaching as a learned skill, development of clinician identity formation as educators, development of interprofessional communication skills, increased awareness of the roles of other health professions, and an increased understanding of leadership. Participants expressed a desire for additional opportunities for interprofessional networking and peer teaching. A good level of competence in facilitation skills was reached by participants. CONCLUSION: The SIFT program provided a sustainable framework for health professional students to develop and evidence their teaching and leadership skills in an interprofessional context. This study highlighted the important role of observation, assessment and feedback in student teacher training programs. The process of clear assessment guidelines, direct observation with feedback from supervisors provided a way to ensure quality improvement in peer teaching. The SIFT program will help to build capacity of interprofessional programs where large numbers of teachers are required for small group teaching. The next step will be to ensure a variety of opportunities within interprofessional contexts, and with face-to-face engagement.

The implications of noncompliance for randomized trials with partial nesting due to group treatment.

Analyses of trials of group administered treatments require an identifier for therapy group to account for clustering by group. All patients randomized to receive the group administered treatment could be assigned an intended group identifier following randomization. Alternatively, an actual group could be based on those patients that comply with group therapy. We investigate the implications for intention-to-treat (ITT) analyses of using either the intended or actual group to adjust for the clustering effect. We also consider causal models using the actual group. A simulation study showed that ITT estimates based on random effects models or GEE with an exchangeable correlation matrix performed much better when using the intended group than the actual group. OLS with robust standard errors performed well with both. Most compliance average causal effect (CACE) models performed well. While practical constraints of the clinical setting may determine the choice between an intended or actual group analyses, it is desirable to record both. An ITT analysis using mixed models can then be fitted using the intended group with data generation assumptions checked by a causal model using the actual group. Where an ITT analysis is based on the actual group, worse outcome for never-takers than compliers may allow one to infer that some estimators are biased toward no treatment effect. The work here is motivated and illustrated by a trial of a group therapy, but also has relevance to trials with treatment related clustering due to therapist examples of which include physical and talking therapies or surgery.

Testicular Workup for Ischemia and Suspected Torsion in Pediatric Patients and Resource Utilization.

BACKGROUND: Testicular torsion (TT) is a pediatric emergency requiring prompt diagnosis and management. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) scores patients on clinical symptoms and can predict TT. This study aimed to determine if the application of TWIST to children with acute scrotal pain could decrease the use of Doppler ultrasonography (DUS) and emergency department (ED) length of stay and ischemic time. MATERIALS AND METHODS: A retrospective cohort study applying TWIST to patients who presented to a pediatric ED with acute testicular pain from December 2017 to June 2019 was performed. Demographics, TWIST score, diagnosis, DUS, consults, and time to the operation were recorded. Patients were stratified into low (LR), intermediate (IR), and high (HR) risk groups for TT based on TWIST score. Descriptive and comparative analyses were performed. RESULTS: Seventy-seven patients were included in the study and had a mean age of 9.24 y ±5.24. All 9 HR patients (TWIST = 5-7) had TT, and none of the 57 LR patients (TWIST = 0-2) had TT. Use of TWIST could have reduced the number of DUS needed to diagnose TT from 69 to 11 (75.3% reduction in DUS). CONCLUSIONS: TWIST accurately predicts torsion in HR groups and excludes torsion in LR groups. Application of TWIST to HR patients may eliminate the need for DUS and decrease ischemic time and cost of care. Application of TWIST in LR patients may likewise eliminate the need for DUS and decrease ED length of stay and cost of care.

An integrated parenting intervention for maternal depression and child development in a low-resource setting: Cluster randomized controlled trial.

BACKGROUND: Rates of depression among Pakistani mothers are high, leading to poor developmental outcomes in their children. This study tested the effectiveness of a manualized integrated parenting program; Learning through Play Plus (LTP+) for maternal depression in Karachi, Pakistan. METHODS: A cluster randomized control trial conducted from January 2014 to December 2015 across 120 villages in Karachi. A total of 774 depressed mothers aged 18-44 years with children aged 0-30 months old, were included. Villages were randomized to receive LTP+ added to treatment as usual (TAU) or TAU alone. Primary outcomes were severity of maternal depression at 3 and 6 months measured by the Edinburgh Postnatal Depression Scale and child socio-emotional development at 6 months measured by the Ages and Stages Questionnaire (ASQ). Secondary outcomes included maternal anxiety, quality of life, social support, parenting competence, and knowledge about child development. RESULTS: Mothers in the LTP+ group reported significantly lower depression scores compared to those in the TAU group (6.6 vs. 13.8, effect size [ES]: -7.2; 95% confidence interval [CI]: -8.2, -6.1) at 3 and 6 months (7.2 vs. 12.00; ES: -4.6; 95% CI: -5.9, -3.4). Child socio-emotional development at 6 months was significantly better in the LTP+ group on all domains of the ASQ. There were also statistically significant improvements on all secondary outcomes at 3- and 6-month follow-up. CONCLUSION: In low-resource settings like Pakistan, low-cost integrated parenting interventions delivered by lay health workers can provide effective treatment for depressed mothers, leading to improvements in child development.

Exploring complexities in the reform of assessment practice: a critical realist perspective.

Although the principles behind assessment for and as learning are well-established, there can be a struggle when reforming traditional assessment of learning to a program which encompasses assessment for and as learning. When introducing and reporting reforms, tensions in faculty may arise because of differing beliefs about the relationship between assessment and learning and the rules for the validity of assessments. Traditional systems of assessment of learning privilege objective, structured quantification of learners' performances, and are done to the students. Newer systems of assessment promote assessment for learning, emphasise subjectivity, collate data from multiple sources, emphasise narrative-rich feedback to promote learner agency, and are done with the students. This contrast has implications for implementation and evaluative research. Research of assessment which is done to students typically asks, "what works", whereas assessment that is done with the students focuses on more complex questions such as "what works, for whom, in which context, and why?" We applied such a critical realist perspective drawing on the interplay between structure and agency, and a systems approach to explore what theory says about introducing programmatic assessment in the context of pre-existing traditional approaches. Using a reflective technique, the internal conversation, we developed four factors that can assist educators considering major change to assessment practice in their own contexts. These include enabling positive learner agency and engagement; establishing argument-based validity frameworks; designing purposeful and eclectic evidence-based assessment tasks; and developing a shared narrative that promotes reflexivity in appreciating the complex relationships between assessment and learning.

Total wrist arthrodesis with and without arthrodesis of the carpoMetacarpal joint (WAWWAM): study protocol.

BACKGROUND: It is controversial whether or not the carpometacarpal joint (CMCJ) should be included in total wrist arthrodesis (TWA). Complications commonly occur at this site and studies examining its inclusion and exclusion are conflicting. A randomised clinical trial comparing wrist arthrodesis with CMCJ arthrodesis and spanning plate to wrist arthrodesis with CMCJ preservation and non-CMCJ spanning plate has not been performed. METHOD: A single centre randomised clinical trial including 120 adults with end-stage isolated wrist arthritis will be performed to compare TWA with and without the CMCJ included in the arthrodesis. The primary outcome is complications in the first post-operative year. Secondary outcomes are Disabilities of the Arm, Shoulder and Hand (DASH) score, Patient Rated Wrist Evaluation (PRWE) and grip strength measured at 1, 2 and 5 years. Late complications, return to work and satisfaction will also be recorded. DISCUSSION: It is unknown whether the CMCJ should be included in TWA. This trial will contribute to an improved understanding of optimal management of the CMCJ in total wrist arthrodesis. TRIAL REGISTRATION: This trial was prospectively registered with the Australia New Zealand Clinical Trials Registry with identifying number ACTRN12621000169842 on the 16th February 2021. WHO: U1111-12626523. ANZCTR: ACTRN12621000169842.

A Transdisciplinary Complex Adaptive Systems (T-CAS) Approach to Developing a National School-Based Culture of Prevention for Health Improvement: the School Health Research Network (SHRN) in Wales.

The paper reflects on a transdisciplinary complex adaptive systems (T-CAS) approach to the development of a school health research network (SHRN) in Wales for a national culture of prevention for health improvement in schools. A T-CAS approach focuses on key stages and activities within a continuous network cycle to facilitate systems level change. The theory highlights the importance of establishing transdisciplinary strategic partnerships to identify and develop opportunities for system reorientation. Investment in and the linking of resources develops the capacity for key social agents to take advantage of disruption points in the re-orientated system, and engagement activities develop the network to facilitate new social interactions and opportunities for transdisciplinary activities. A focus on transdisciplinary action research to co-produce interventions, generate research evidence and inform policy and practice is shown to play an important part in developing new normative processes that act to self-regulate the emerging system. Finally, the provision of reciprocal network benefits provides critical feedback loops that stabilise the emerging adaptive system and promote the network cycle. SHRN is shown to have embedded itself in the system by securing sustainability funding from health and education, a key role in national and regional planning and recruiting every eligible school to the network. It has begun to reorient the system to one of evidence generation (56 research studies co-produced) and opportunities for data-led practice at multiple levels. Further capacity development will be required to capitalise on these. The advantages of a complex systems approach to address barriers to change and the transferability of a T-CAS network approach across settings and cultures are highlighted.

Designing health professional education curricula using systems thinking perspectives.

BACKGROUND: Medical students navigate complex personal learning pathways from entry into medical school, through an educational program, and into life-long practice. However, many stakeholders have called for substantive reforms in contemporary curricula, citing concerns about the lack of key abilities amongst newly graduated doctors to work in complex healthcare environments. Despite the need for educators to focus on curricula design, there is a paucity of overarching perspectives that allow synthesis of the various curricular elements in a way that lends meaningfulness and appreciation to the students in terms of navigating the immediate program requirements and beyond. Without such guidance, educators risk creating fragmented program designs that can lead to both unintended and unactionable outcomes for students as well as curriculum designers. Using systems thinking, we set out to address this gap by providing an overarching perspective for curriculum designers to appreciate the relationships and the interactions of the various curricular elements that inform and impact student's preparedness for practice. METHODS: By framing a curriculum as a complex adaptive system, we used soft systems thinking to develop an initial prototype of a conceptual curricular toolkit, underpinned by an appraisal of relevant literature within health professional education and the broader educational context. The prototype was further refined iteratively after critical reflection by the authors with a diverse range of national and international colleagues via posters, short communications, and workshops at several conferences, and through social media. RESULTS: We describe how the 3P-6Cs toolkit captures a learner's personal journey through an educational program into a field of practice by logically linking the three key elements: the personal, the program, and the practice. We demonstrate its application in three examples related to contemporary health profession education curricula. These are: creating integrated educational designs to capture students' developmental continua, conceptualising immersive clinical placements in non-traditional settings, and complexity-consistent evaluation of curricular interventions. CONCLUSION: Applying the 3P-6Cs curricular toolkit to problems of curricula (re)design can provide overarching perspectives that enable educators to have a better understanding of how integration of elements within education programs can inform and impact student's preparation for lifelong practice.

Optimising student-led interprofessional learning across eleven health disciplines.

BACKGROUND: Provision of effective Interprofessional learning (IPL) opportunities plays a vital role in preparing healthcare students for future collaborative practice. There is an identified need for universities to better prepare students for interprofessional teamwork, however, few large-scale IPL activities have been reported. Additionally, little has been reported on disciplinary differences in student learning experience. The Health Collaboration Challenge (HCC) is a large-scale IPL activity held annually at the University of Sydney. This study sought to explore students' experience of early participation in an interprofessional case-based learning activity, and the similarities and differences in the perceived value of interprofessional (social) learning for each discipline. METHODS: In 2018, 1674 students from 11 disciplines (dentistry, oral health, nursing, pharmacy, medicine, occupational therapy, speech pathology, physiotherapy, dietetics, diagnostic radiography, exercise physiology) participated in the HCC. Students worked in teams to produce a video and patient management plan based on a patient case. Participants completed a questionnaire, including closed and open-ended items. Quantitative data were analysed using descriptive statistics. Thematic analysis was used to code and categorise qualitative data into themes. These themes were then applied and quantified at a disciplinary level to measure prevalence. RESULTS: In total, 584/1674 (35%) of participants responded to the questionnaire. Overall, students perceived their experience to be largely beneficial to their learning and interprofessional skill development. Positive aspects included opportunities for peer learning, collaboration, networking, and understanding the different roles and responsibilities of other health professions. Negative aspects included the video form of assessment, inequity in assessment weighting across disciplines, the discipline mix within teams and lack of case relevance. CONCLUSION: The learning activity provided a framework for students to practice and develop their skills in interprofessional teamwork, as they prepare for increased clinical placements. Overall, students perceived their experience as beneficial to their learning and professional development early in their degree. However, they expressed dissatisfaction with the inequity of assessment weighting across the disciplines; lack of relevance of the case across disciplines; and the activity of producing a video. Further research is needed regarding the ideal number of disciplines to include in teamwork specific to a patient case.