Integrating patient management, reflective practice, and ethical decision-making in an emergency medicine intern boot camp.

BACKGROUND: Integration of clinical skills, ethical decision-making, and reflection skills have emerged as cornerstones of clinical teaching in medical schools. This study aimed to detect whether a multimodal learning environment approach consisting of lectures, a drill, post-drill video debriefing, and written reflection in an emergency medicine rotation boot camp improves interns' patient management skills, ethical decision-making, and reflection skills. METHODS: A multimodal learning environment was created by the collaboration of emergency medicine, ethics, and medical education specialists. Multiple educational techniques involving lectures, case discussions, and role-playing a crisis scenario were applied. Pre-test and post-test, debriefing on performances on video records, video-recorded performance assessment, and reflective essays about their own and group's performances were used to assess various aspects of the student performances. Additionally, a meeting was organized with the presence of the authors to create qualitative data obtained through the program evaluation meeting conducted on three themes: influences of teaching methods, students' performances, and common achievements and mistakes of students. RESULTS: 133 students participated. Post-test multiple-choice question (MCQ) test scores were slightly higher than pre-test. A low and medium correlation was detected among pre-test and post-test patient management problem (PMP) and reflection scores, which was more prominent for female students. Multiple linear regression showed that pre-test and post-test PMP scores significantly contributed to reflection scores. These results might support that better patient management predicts more robust reflective practice. Teachers observed that students appreciated being inspired by well-performing peers, particularly noting the empathic needs of patients, companions, and other health professionals. However, students overlooked summoning forensic or social services and were inhibited by the pressure of the contextual traits of the drill. CONCLUSION: The multimodal learning environment created by multidisciplinary collaboration contributed to the improvement of components of situational awareness of the interns: patient management skills, ethical decision-making, and reflective practice. During this research, we created a toolbox better to capture the richness and diversity of student interactions. Considering the scarcity of context-specific assessment methods and widespread use of MCQs or generic scales for higher-order thinking skills in medicine, this study might be regarded as a step forward in that context.

Perceptions of Turkish dentists of their professional identity in a market-orientated system.

This study explores the perceptions of Turkish dentists of their professional identity and of the effects of market orientation in dentistry. This phenomenological study used a qualitative approach using a group of Turkish dentists, who were selected based on the principle of maximum variation. Four focus groups and 31 in-depth interviews were conducted. Forty-nine dentists were interviewed using a semi-structured form. The data analysis yielded three themes: (a) dentistry as a business; (b) dentistry as a profession; and (c) professional status of dentistry in the health care system and in the community. The participants' statements reflected that the dominance of market mechanisms in dentistry inevitably forces dentists to adopt the characteristics of a business person and prevents them from fulfilling the basic requirements of professionalism. All participants explained that with the transformation of the dental care market, dentists have become a cheap labor force and have lost their professional autonomy. Our study has confirmed previous reports pointing out the conflict between dentistry as a profession and dentistry as a commercial operation. The study also showed that in Turkey, as a country experiencing rapid reform processes, dentists' control over their professional practices and identities has decreased.

Exposure of medical students to pharmaceutical marketing in primary care settings: frequent and influential.

It is known that interaction between pharmaceutical companies and medical professionals may lead to corruption of professional values, irrational use of medicine, and negative effects on the patient-physician relationship. Medical students frequently interact with pharmaceutical company representatives and increasingly accept their gifts. Considering the move toward early clinical encounters and community-based education, which expose students early to pharmaceutical representatives, the influence of those gifts is becoming a matter of concern. This study examines the frequency and influence of student exposure to drug marketing in primary care settings, as well as student perceptions of physician-pharmaceutical company relationships. This was a two-phase study consisting of qualitative research followed by a cross-sectional survey. Clinical experience logbooks of 280 second-year students in one school were analysed, and the themes that emerged were used to develop a survey that was administered to 308 third-year students from two medical schools. Survey results showed a 91.2% exposure to any type of marketing, and 56.8% of students were exposed to all classes of marketing methods studied. Deliberate targeting of students by pharmaceutical representatives, in particular, was correlated with being less sensitive to the negative effects of and having positive opinions about interactions with pharmaceutical companies. The vast majority of students are exposed to drug marketing in primary care settings, and may become more vulnerable to that strategy. Considering that medical students are vulnerable and are targeted deliberately by pharmaceutical companies, interventions aimed at developing skills in the rational use of medicines and in strategies for coping with drug marketing should be devised.

Factors determining students' global satisfaction with clerkships: an analysis of a two year students' ratings database.

Clerkships would benefit from teachers' improved understanding of the didactic aspects of their task. The purpose of this study is to identify factors that determine the teaching quality of clerkships and to examine the predictive value of these factors for students' global satisfaction. Thus, results would be further reflected to clinical teachers' tasks. These factors could then be taken into account in future clinical teaching. In this paper, a medical faculty's 2 year data set of student feedback from a systematic programme evaluation project was used. A factor analysis was performed on 11,780 student questionnaires. Factor loads, and the Cronbach's alpha coefficients of the questionnaire and factors were calculated. In order to examine the contributions of the factors to the students' global satisfaction, the study included a multivariate stepwise regression analysis. The analysis revealed four factors, which together explained 60.24% of the variance: Structure & Process (44.66%); Time (5.8 %); Outcome (5.35%) and Input (4.39%). The Structure & Process factor was found to be the best predictor of students' global satisfaction (R2 =( ).537). Our conclusion is that "efforts to improve clerkship quality should focus on students' learning processes and clerkship structure".

Ethical problems in an era where disasters have become a part of daily life: A qualitative study of healthcare workers in Turkey.

BACKGROUND: Natural disasters, armed conflict, migration, and epidemics today occur more frequently, causing more death, displacement of people and economic loss. Their burden on health systems and healthcare workers (HCWs) is getting heavier accordingly. The ethical problems that arise in disaster settings may be different than the ones in daily practice, and can cause preventable harm or the violation of basic human rights. Understanding the types and the determinants of ethical challenges is crucial in order to find the most benevolent action while respecting the dignity of those affected people. Considering the limited scope of studies on ethical challenges within disaster settings, we set upon conducting a qualitative study among local HCWs. METHODS: Our study was conducted in six cities of Turkey, a country where disasters are frequent, including armed conflict, terrorist attacks and a massive influx of refugees. In-depth interviews were carried out with a total of 31 HCWs working with various backgrounds and experience. Data analysis was done concurrently with ongoing interviews. RESULTS: Several fundamental elements currently hinder ethics in relief work. Attitudes of public authorities, politicians and relief organizations, the mismanagement of impromptu humanitarian action and relief and the media's mindset create ethical problems on the macro-level such as discrimination, unjust resource allocation and violation of personal rights, and can also directly cause or facilitate the emergence of problems on the micro-level. An important component which prevents humanitarian action towards victims is insufficient competence. The duty to care during epidemics and armed conflicts becomes controversial. Many participants defend a paternalistic approach related to autonomy. Confidentiality and privacy are either neglected or cannot be secured. CONCLUSION: Intervention in factors on the macro-level could have a significant effect in problem prevention. Improving guidelines and professional codes as well as educating HCWs are also areas for improvement. Also, ethical questions exposed within this study should be deliberated and actualized with universal consensus in order to guide HCWs and increase humane attitudes.

Medical Students' Opinions About the Commercialization of Healthcare: A Cross-Sectional Survey.

There are serious concerns about the commercialization of healthcare and adoption of the business approach in medicine. As market dynamics endanger established professional values, healthcare workers face more complicated ethical dilemmas in their daily practice. The aim of this study was to investigate the willingness of medical students to accept the assertions of commercialized healthcare and the factors affecting their level of agreement, factors which could influence their moral stance when market demands conflict with professional values. A cross-sectional study was conducted in three medical schools in Turkey. The study population consisted of first-, third-, and sixth-year students, and 1,781 students participated in total. Students were asked to state if they agreed with the assertions of commercialized healthcare. Of all students, 87.2 per cent agreed with at least one of the assertions, and one-fifth (20.8 per cent) of them agreed with more than half of the assertions. First-year students significantly agreed more with some assertions than third- and sixth-year students. Being female, having mid-level family income, choosing medicine due to idealistic reasons, and being in the third or sixth years of medical study increased the probability of disagreement. Also, studying in a medical school that included integrated lectures on health policies, rights related to health, and health inequities, along with early field visits, increased the probability of disagreement. This study suggests that agreement with the assertions of commercialized healthcare might be prevalent among students at a considerable level. We argue that this level of agreement is not compatible with best practice in professional ethics and indicates the need for an educational intervention in order to have physicians who give priority to patients' best interests in the face of market demands.

[Specialist training in basic sciences in university hospitals: specialist resident perspective]. / Universite hastanelerinde temel bilimler alaninda uzmanlik egitimi: tipta uzmanlik ögrencisi bakis açisi ile.

In this study, a questionnaire survey including 56 questions and 154 variables has been undertaken for 74 specialist residents (SpRs) (39 from Dokuz Eylül and 35 from Ege Universities) who have been training in the two university hospitals of Izmir, for the detection of the structure of the actual training programmes, trainer profiles and technical institute equipments in the departments of Basic Sciences, Medical Pathology and Pharmacology. By using this survey, SpRs' demographic informations, training programmes, theoretical and skill activites, educational atmospheres, the trainers' profiles, assessments, audits and professionel developments have been questionned. The rate of response was 71%, and educational programmes, training and technical equipments, efficacy and number of the trainers were found satisfactory in each one of the universities. It has been detected that, the SpRs were permanently assessed and they were able to get training knowledges, skills and attitutes and attend investigation activities during their educational process. This survey study indicated that the training programmes, institute equipments and trainer profiles of the universities were competent for the SpRs'.

Secular trend of menarche age in an immigrant urban city in Turkey: Izmir.

The purpose of this study was to investigate the secular trend of menarche age within the last 35 years in an immigrant urban city in Turkey-Izmir. We found the mean age at menarche as 13.10±1.18 years for 121,257 women. The reported mean age at menarche showed a decreasing trend over time. For women born before 1963 (≥40 years of age), the mean age at menarche was 13.08±1.21 years. For women born from 1964-1973 (30-39 years of age), the mean age at menarche was 13.12±1.19 years. For women born from 1974-1983 (20-29 years of age), the mean age at menarche was 13.11±1.18 years, and for those born after 1984 (15-19 years of age), the mean age at menarche was 13.06±1.16 years (p=0.000). When divided according to socioeconomic status, the mean age at menarche was 13.11±1.11 in the high socioeconomic group, 13.22±1.25 in the middle socioeconomic group, and 12.75±1.02 in the low socioeconomic group (p=0.000). In conclusion, in the Turkish population, the mean age at menarche has decreased from 13.12 to 13.06 over the past 30 years, and the mean age at menarche was lower in the low socioeconomic group.

Assessing medical student competency in communication in the pre-clinical phase: objective structured video exam and SP exam.

OBJECTIVE: The aim of our study was to present the structure, process and results of the objective structured video exam and One-Station standardized patient exam that have been used to assess second year medical students' communication skills. METHODS: Scores of 1137 students between the years 2007 and 2010 were analyzed. Means and standard deviations were calculated for scores and ratings. Internal consistency was assessed using Cronbach's alpha coefficient. To analyze reliability and generalizability, multivariate generalizability theory was employed. RESULTS: Students' total and item scores on the objective structured video exam (60.5-68.8) were lower than on the One-Station standardized patient exam (90.4-96.6). Internal consistencies of both exams were moderate. Generalizability analysis and D-study results showed that both the objective structured video exam and the One-Station standardized patient exam need improvement. CONCLUSION: Both exams need measures to improve them, such as increasing the number of video cases or stations, and further standardization of raters. PRACTICE IMPLICATIONS: This study might encourage medical teachers to consider assessing validity and reliability of written and performance exams on the basis of generalizability theory, and to find out feasible actions to improve assessment procedures by conducting a D-study.

Validity and reliability of the Turkish version of the Hill-Bone compliance to high blood pressure therapy scale for use in primary health care settings.

OBJECTIVES: To assess the validity and reliability of the Turkish version of the Hill-Bone compliance to high blood pressure therapy scale for use in primary care in Turkey. METHODS: To develop a Turkish version of the scale, it was translated into Turkish then back-translated into English. The final version was used in a survey in two urban primary health care centers in Izmir, Turkey. For assessing the validity of Turkish scale, we performed factor analysis to test construct validity. Reliability was assessed by calculating the Cronbach's alpha as a measure of internal consistency. RESULTS: Factor analysis revealed a three-factor structure representing unintentional medication non-adherence; intentional medication non-adherence; and salt intake adherence. Percentages of explained variance were 33.3%, 14.6% and 11.2% respectively. When forcing a two-factor structure we found salt intake and medication adherence clusters. Cronbach's alpha was 0.72 and 0.83 for medication adherence and whole scale, respectively. CONCLUSION: The Turkish Hill-Bone scale presented a factor structure consistent with the original scale, had a high level of internal consistency. It can be used for assessing hypertension patients' compliance in Turkish primary care settings.