The extent of polypharmacy and use of 'fall risk increasing drugs' in the oldest old admitted to a regional New South Wales hospital.

OBJECTIVE(S): Polypharmacy is associated with significant morbidity including cognitive decline and falls. We sought to quantify the extent of polypharmacy and use of medications associated with fall risk in the very old admitted to a regional NSW hospital. METHODS: Cross-sectional study of patients aged over 80 years admitted to a regional NSW hospital from September to October 2019. Demographic data and medication usage on admission were collected. Polypharmacy was defined as regular use of five or more medications. RESULTS: A total of 401 patients were included: mean age was 87.2 (±4.6) years and 56.9% were female. Of the participations, 82.9% experienced polypharmacy, and the mean number of medications was 8.2 (±4.2). Of the patients, 91.6% utilised medications associated with risk of falls. There was no association between age and number of preadmission regular medications. CONCLUSION: Polypharmacy is extremely common prior to acute hospitalisation for regional older individuals. This highlights the importance of medication rationalisation to reduce medication-related harm.

Relevance of anatomy to medical education and clinical practice: perspectives of medical students, clinicians, and educators.

INTRODUCTION: Against a backdrop of ever-changing diagnostic and treatment modalities, stakeholder perceptions (medical students, clinicians, anatomy educators) are crucial for the design of an anatomy curriculum which fulfils the criteria required for safe medical practice. This study compared perceptions of students, practising clinicians, and anatomy educators with respect to the relevance of anatomy education to medicine. METHODS: A quantitative survey was administered to undergraduate entry (n = 352) and graduate entry students (n = 219) at two Irish medical schools, recently graduated Irish clinicians (n = 146), and anatomy educators based in Irish and British medical schools (n = 30). Areas addressed included the association of anatomy with medical education and clinical practice, mode of instruction, and curriculum duration. RESULTS: Graduate-entry students were less likely to associate anatomy with the development of professionalism, teamwork skills, or improved awareness of ethics in medicine. Clinicians highlighted the challenge of tailoring anatomy education to increase student readiness to function effectively in a clinical role. Anatomy educators indicated dissatisfaction with the time available for anatomy within medical curricula, and were equivocal about whether curriculum content should be responsive to societal feedback. CONCLUSIONS: The group differences identified in the current study highlight areas and requirements which medical education curriculum developers should be sensitive to when designing anatomy courses.

Global sharing, local innovation: Four schools, four countries, one curriculum.

BACKGROUND: Many internal and external obstacles, must be overcome when establishing a new medical school, or when radically revising an existing medical curriculum. AIMS: Twenty-five years after the Flinders University curriculum was introduced as the first graduate-entry medical programme (GEMP) in Australia, we aim at describing how it has been adopted and adapted by several other schools, in Australia and in Europe (UK, Ireland, and Portugal). METHOD/RESULTS: This paper reports on the experience of four schools establishing a new medical school or new curriculum at different times and in different settings. CONCLUSIONS: We believe that these experiences might be of interest to others contemplating a similar development.

Studying medicine - a cross-sectional questionnaire-based analysis of the motivational factors which influence graduate and undergraduate entrants in Ireland.

OBJECTIVES: The number of places available in Ireland for graduate entry to medical school has steadily increased since 2006. Few studies have, however, characterized the motivational factors underlying decision to study medicine via this route. We compared the factors motivating graduate entrants versus undergraduate entry (UGE) students to choose medicine as a course of study. DESIGN: The present study was a quantitative cross-sectional questionnaire-based investigation. SETTING: The study was conducted in University College Cork and University of Limerick, Ireland. PARTICIPANTS: It involved 185 graduate entry (GE) and 120 UGE students. OUTCOME MEASURES: QUESTIONNAIRES WERE DISTRIBUTED TO STUDENTS ADDRESSING THE FOLLOWING AREAS: demographic/academic characteristics; factors influencing the selection of academic institution and motivation to study medicine; and the role of career guidance in choice of study. RESULTS: When asked to list reasons for selecting medicine, both groups listed a wish to help and work with people, and a desire to prevent and cure disease. UGE students were significantly more motivated by intellectual satisfaction, encouragement by family/friends, financial reasons, and professional independence. Approximately half of GE students selected their first degree with a view to potentially studying medicine in the future. GE and UGE students differed significantly with respect to sources consulted for career guidance and source of study information. CONCLUSIONS: This study is the first systematic examination of study and career motivation in GE medical students since the programme was offered by Irish universities and provides insight into the reasons why graduate entrants in Ireland choose to study medicine via this route.

The first survey of attitudes of medical students in Ireland towards termination of pregnancy.

BACKGROUND: Since the UK Abortion Act (1967), women have travelled from Ireland to the UK for legal abortion. In 2011 >4000 women did so. Knowledge and attitudes of medical students towards abortion have been published, however, this is the first such report from Ireland. OBJECTIVE: To investigate medical students' attitudes towards abortion in Ireland. METHODS: All medical students at the University of Limerick, and physicians who graduated from the university within the previous 12 months, were invited via email to complete an anonymous online survey. The questionnaire comprised 17 questions. Quantitative and qualitative analyses were performed. RESULTS: Response rate was 45% (n=169; 55% women; 88.2% <30 years of age; 66.7% Irish; 29.2% North American). Outcomes were: abortion should not be legally available (7.1%), abortion should be allowed in limited circumstances only (35.5%), abortion should be legally available upon request (55%). 72.8% of respondents were moderately/strongly prochoice (74% of women/71% of men/72% and 76% of Irish and North American respondents, respectively). Students aged >30 years were less likely to be prochoice (55%). While 95.2% believed that education on abortion should be offered within medical school curricula, 28.8% stated that they would decline to terminate pregnancies even if legally permitted. While 58.8% indicated that they might perform legal abortions once qualified, 25.7% would do so under limited circumstances only. CONCLUSIONS: The majority of participants wanted education regarding abortion. Despite being predominantly prochoice, considerably fewer students, irrespective of nationality, indicated that they would perform abortions.

Demographic attributes and knowledge acquisition among graduate-entry medical students.

BACKGROUND: Recent changes to undergraduate (basic) medical education in Ireland have linked an expansion of student numbers with wide-ranging reforms. Medical schools have broadened access by admitting more mature students from diverse backgrounds and have increased their international student numbers. This has resulted in major changes to the demographic profile of students at Irish medical schools. AIM: To determine whether the demographic characteristics of students impact on their academic performance and specifically on their rate of knowledge acquisition. METHODS: As a formative assessment exercise, we administered a progress test to all students twice each year during a 4 year graduate-entry medical programme. We compared scores over time between students from different age cohorts, of different gender, of different nationalities and from different academic backgrounds. RESULTS: In the 1143 tests taken by 285 students to date, there were no significant differences in the rate of knowledge acquisition between the various groups. Early in the course, students from a non-biological science background performed less well than others but outperformed their peers by the time of graduation. CONCLUSION: Neither age, gender, nationality nor academic background impacts on the rate of knowledge acquisition among graduate-entry medical students.

Assessment of waist-worn tri-axial accelerometer based fall-detection algorithms using continuous unsupervised activities.

This study aims to evaluate a variety of existing and novel fall detection algorithms, for a waist mounted accelerometer based system. Algorithms were tested against a comprehensive data-set recorded from 10 young healthy subjects performing 240 falls and 120 activities of daily living and 10 elderly healthy subjects performing 240 scripted and 52.4 hours of continuous unscripted normal activities.

Cross-institutional progress testing: feasibility and value to a new medical school.

OBJECTIVES: This study aimed to examine the feasibility of using a progress test to compare the rate of knowledge acquisition among students at a new medical school with that of students at a comparable but long-established school. METHODS: As part of an ongoing strategy, we administered the McMaster Personal Progress Index (PPI) on four occasions to the first two cohorts of students enrolled in the graduate-entry medical programme at the University of Limerick. We compared mean PPI scores for students at comparable stages in their courses at both schools. RESULTS: To date, the rate of knowledge acquisition is similar in students at both schools. CONCLUSIONS: Inter-institutional and international collaboration in progress testing is feasible and provides a useful quality assurance tool which can be used by new schools to reassure students, faculty members and accrediting bodies.

The financial costs of delivering problem-based learning in a new, graduate-entry medical programme.

CONTEXT: In discussions of the merits and limitations of problem-based learning (PBL) as an educational methodology, the cost of its delivery is often cited as a significant issue. Although there appears to be no shortage of opinion as to the perceived cost of PBL, we know of no institution that has accurately measured its cost, even in financial terms. Where factual information is lacking, opinion and misconception tend to proliferate. In setting up a new, graduate-entry medical programme on a greenfield site at the University of Limerick, we took the opportunity to calculate both the initial and recurring costs of our particular approach to the delivery of PBL. METHODS: We calculated the initial cost of providing purpose-built facilities to deliver PBL to 240 students in the first 2 years of our 4-year programme. We also calculated the annual recurring costs of delivering PBL, based on having a student : tutor ratio of 8 : 1 and on having tutors who are all medically qualified, who are reasonably well remunerated for their work and who each deliver 5 hours of PBL tutoring per week. RESULTS: The initial cost of delivering PBL was calculated as euro 1,526,952 (equivalent to pound sterling 1,369,138 or US$2,050,375). The annual recurring cost of PBL approximates euro 664,000/year (at time of writing equivalent to pound sterling 527,000 and US$988,000). This recurring cost equates to euro 2767/student/year, 89% of which relates to tutor salaries. CONCLUSIONS: Although the cost of delivering PBL will be greatly influenced by the approach taken at different institutions, we hope that a breakdown of costs at our institution will contribute to the ongoing debate on the strengths and weaknesses of PBL.

A new direction for medical education in Ireland?

In recent years, new concepts of educational theory and practice have stimulated new approaches to medical education in many countries. For various reasons, medical education in Ireland has been slow to change such that there are now increasing concerns about educational standards. In addition, Ireland currently produces too few doctors and is therefore highly dependent on overseas doctors to maintain its health service. The responsible agencies are finally about to address these problems through a major expansion of medical education coupled with a strong agenda for educational reform. While the reform process will clearly be influenced by the experience of other counties, Ireland now has a great opportunity to take innovation in medical education a step further. For example, there is now an opportunity to develop new strategies to ensure the social accountability of medical education, to increase its community orientation and to foster interprofessional teaching and learning.

Working and training as an intern: a national survey of Irish interns.

The Medical Council of Ireland recently introduced some initiatives to enhance the education and training of interns. These include the development of a generic job description, a logbook to monitor training outcomes and a national network of supervisors to plan and oversee intern training. To get feedback on the impact of these reforms, the Medical Council surveyed all interns with Irish addresses in March 2003. Three hundred (65%) of 461 interns responded. The majority provided positive feedback on many aspects of their education and training, their work environment and professional relationships. However, a majority also reported a lack of protected time for education, a lack of formal educational programmes, insufficient feedback on performance and an unnecessarily stressful work environment. Overall, 61% reported being bullied and 4% had experienced sexual harassment. While feedback on the Irish internship experience is generally positive, further work is necessary to address the problems identified.

An outreach intervention to implement evidence based practice in residential care: a randomized controlled trial [ISRCTN67855475].

BACKGROUND: The aim of this project was to assess whether outreach visits would improve the implementation of evidence based clinical practice in the area of falls reduction and stroke prevention in a residential care setting. METHODS: Twenty facilities took part in a randomized controlled trial with a seven month follow-up period. Two outreach visits were delivered by a pharmacist. At the first a summary of the relevant evidence was provided and at the second detailed audit information was provided about fall rates, psychotropic drug prescribing and stroke risk reduction practices (BP monitoring, aspirin and warfarin use) for the facility relevant to the physician. The effect of the interventions was determined via pre- and post-intervention case note audit. Outcomes included change in percentage patients at risk of falling who fell in a three month period prior to follow-up and changes in use of psychotropic medications. Chi-square tests, independent samples t-test, and logistic regression were used in the analysis. RESULTS: Data were available from case notes at baseline (n = 897) and seven months follow-up (n = 902), 452 residential care staff were surveyed and 121 physicians were involved with 61 receiving outreach visits. Pre-and post-intervention data were available for 715 participants. There were no differences between the intervention and control groups for the three month fall rate. We were unable to detect statistically significant differences between groups for the psychotropic drug use of the patients before or after the intervention. The exception was significantly greater use of "as required" antipsychotics in the intervention group compared with the control group after the pharmacy intervention (RR = 4.95; 95%CI 1.69-14.50). There was no statistically significant difference between groups for the numbers of patients "at risk of stroke" on aspirin at follow-up. CONCLUSIONS: While the strategy was well received by the physicians involved, there was no change in prescribing patterns. Patient care in residential settings is complex and involves contributions from the patient's physician, family and residential care staff. The project highlights challenges of delivering evidence based care in a setting in which there is a paucity of well controlled trial evidence but where significant health outcomes can be attained.

A comparison of performance assessment programs for medical practitioners in Canada, Australia, New Zealand, and the United kingdom.

PURPOSE: To compare programs designed to assess the performance of practicing doctors in Canada, Australia, New Zealand, and the United Kingdom. METHODS: Senior representatives of 11 organizations undertaking performance assessments were invited to provide a description of their programs, using a standardized written questionnaire. RESULTS: Collectively, the 11 organizations provide 16 performance assessment programs that operate on three levels: those that screen populations of doctors (Level 1), those that target "at risk" groups (Level 2), and those that assess individuals who may be performing poorly (Level 3). The 16 programs differ in such areas as the number of doctors enrolled, the number of assessments undertaken, the referral mechanisms, the outcomes of assessment, and in the resources provided for the task. They particularly differ in their choice of tools to assess performance. CONCLUSION: Although a uniform international approach to performance assessment may be neither feasible nor desirable, an international comparison of current practice, as provided in this report, should stimulate further debate on the development of better performance assessment processes.

Reforming medical education to enhance the management of chronic disease.

Medical education must adapt to change if it is to remain relevant to the needs of doctors, patients and society. Ideally, it should anticipate and lead change. Undergraduate education remains rooted in urban medical schools where the focus is on acute disease, while most graduates spend their working lives in the community, dealing mainly with chronic health problems. Medical graduates need to acquire specific knowledge, skills and attitudes if they are to effectively manage people with chronic disease. Strategies that create a better balance between education in acute and chronic disease are being developed. These include a transfer of clinical teaching to community and nursing home settings and the development of interdisciplinary teaching.

Evidence-based clinical practice in falls prevention: a randomised controlled trial of a falls prevention service.

AIMS: Evidence-based guidelines recommend a range of treatments for falls and injury prevention. We undertook a randomised trial of a falls prevention service to screen for falls risk factors and recommend to GPs an evidenced base prescription for falls prevention. METHODS: All patients who presented with a fall to the Emergency Department at Flinders Medical Centre over a 22-week period were considered for the study. We excluded patients with dementia, resident in high care or those transferred to other hospitals and outside our catchment area. Of those who consented, we randomised patients between usual care or to an intervention consisting of a falls risk assessment and writing of an evidence-based prescription faxed to their GP for action. Patients were followed for six months and uptake of advice and fall rates were monitored. RESULTS: Four hundred and fifty patients presented with a fall-related attendance and of these 261 patients were eligible for inclusion in the trial. Of these 261 patients, 140 consented and were enrolled in the trial. Over the six months patients in the intervention group were more likely to uptake preventative advice (OR=12.3; 95%CI=4.2-35.9). We were unable to show a reduction in falls (OR= 1.7; 95%CI=0.7-4.4). CONCLUSIONS: A patient centered evidence-based approach is feasible and effective in increasing uptake of falls prevention advice. Long term compliance with advice needs further exploration.

Early discharge and home rehabilitation after hip fracture achieves functional improvements: a randomized controlled trial.

OBJECTIVE: To compare hospital and home settings for the rehabilitation of patients following hip fracture. DESIGN: Randomized controlled trial comparing accelerated discharge and home-based rehabilitation (n = 34) with conventional hospital care (n = 32) for patients admitted to hospital with hip fracture. SETTING: Three metropolitan hospitals in Adelaide, Australia. SUBJECTS: Sixty-six patients with fractured hip. INTERVENTIONS: Patients assigned to the home-based rehabilitation group were discharged within 48 hours of randomization. The project team therapists made visits to the patient's home and negotiated a set of realistic, short-term and measurable treatment goals with both the patient and carer. Those randomized to usual care remained in hospital for conventional rehabilitation. MAIN OUTCOME MEASURES: Physical and social dependence, balance confidence, quality of life, carer strain, patient and carer satisfaction, use of community services and incidence of adverse events such as re-admission and falls. RESULTS: While there was no difference between the groups for all measures of quality of life, patients in the accelerated discharge and home-based rehabilitation group recorded a greater improvement in MBI from randomization (p < 0.05) and scored higher on the Falls Efficacy Scale (p < 0.05) at four months. There was no difference in falls rates. Patients in the home-based rehabilitation group had a shorter stay in hospital (p < 0.05) but a longer stay in rehabilitation overall (p < 0.001). The groups were comparable on the rate and length of admissions after discharge, use of community services, need for carer input and contact with general practitioner (GP) after discharge. CONCLUSIONS: This trial further supports the practice of accelerated discharge from hospital and home-based rehabilitation in selected patients recovering from hip fracture. Such a practice appears to improve physical independence and confidence in avoiding subsequent falls which may have implications for longevity and overall quality of life.

Is there a problem with the problems in problem-based learning?

OBJECTIVE: To determine the balance between acute and chronic medical problems in the PBL cases at 2 Australian medical schools. METHODS: Analysis of 162 PBL cases. RESULTS: Cases concentrate on acute problems in young people and neglect chronic disease in the old. CONCLUSION: This imbalance may contribute to negative attitudes towards elderly patients and people with chronic disease.

The new medical curriculum at Flinders University, South Australia: from concept to reality.

After much discussion and planning, Flinders University in Adelaide, South Australia recently introduced a new Graduate-Entry Medical Program (GEMP) which centres on problem-based learning (PBL). We describe the factors that stimulated the development of this new course, discuss its aims and philosophies and provide a brief outline of its structure. Advice and practical help was freely provided by several institutions who had undertaken similarly radical curricular reform and without this, a difficult task would have been much harder. We hope that our experiences will be of interest and help to others who are considering curricular reform.

Clinical problem solving (CPS) as a teaching strategy: a 'dual teacher' approach.

A desire to take a 'problem-solving' approach to clinical teaching, combined with a lack of resources for a 'standard' problem-based learning (PBL) approach prompted the authors to develop a new teaching strategy that builds on the ideas of others and which they call clinical-problem solving (CPS). In this paper, they describe the CPS approach, its perceived strengths and weaknesses, and their experience with it to date. They believe that CPS provides a dynamic learning environment and one that can be adapted to a variety of settings. Perhaps its greatest attribute is its ability to provide a problem-solving approach to learning while requiring far fewer resources than PBL. For example, course material that would have required 300 hours of tutor time in PBL now requires 18 hours of teacher time. CPS also saves on student time and classroom space. The authors consider it to be complementary to, rather than a substitute for, PBL.