Patients' perspectives on factors facilitating adherence to tuberculosis treatment in Iquitos, Peru: a qualitative study.

BACKGROUND: Tuberculosis is a major global health problem and one of the greatest barriers to its control is poor adherence to treatment. Peru has one of the highest burdens of TB in South America, with an incidence rate of 123 per 100,000 populations. There is currently a lack of evidence in South America about factors that facilitate adherence to treatment, with most previous research focusing on factors that negatively influence adherence to TB treatment. SETTING: This study was conducted in Iquitos, the capital city of the Loreto region, north-eastern Peru. Loreto has a high incidence of tuberculosis, estimated at 99 per 100,000 population, and a high poverty rate. METHODS: Twenty face-to-face, semi-structured interviews were conducted at two healthcare centres. Data collected from the interviews was analysed using thematic content analysis. RESULTS: Three main themes emerged from the data set. Personal Qualities, such as responsibility and determination, were perceived as important factors facilitating adherence. Participants described their Trust in Healthcare Providers positively, particularly focusing on their trust in clinical staff, although knowledge of tuberculosis and its treatment was limited. Social Support, from a variety of sources, was also seen as a driving factor for continued adherence. CONCLUSIONS: The results suggest that more emphasis should be placed on educating tuberculosis patients about their disease and its treatment. Additionally, consideration should be given to improving the social support available to patients, for example with tuberculosis support groups involving 'expert' tuberculosis patients.

Language, Philosophy, and Medical Education.

ISSUE: When medical schools began to recognize, a generation ago, that clinical "communication skills" could not be taken for granted among students, a process began of researching them, and introducing the results into curricula. This allowed for a discussion, for the first time, about how doctors should talk to patients, and manage interviews with them. However, there was a focus on a set of behavioral processes which were often unsophisticated with respect to the role of language in communication, or of language as a means of sustaining and describing ambiguity, or language as the primary impetus for educational reflection. EVIDENCE: This paper looks at literature from language studies, the philosophy of language and the philosophy of education to establish the point that, where natural languages are concerned, it is possible and useful to talk of the purposes for which language is used. It is also important to recognize that the meaning of a particular language use is to a substantial extent defined by context: and that languages are excellent vehicles for maintaining and describing ambiguity, where it is impossible to reduce a state of affairs to the well-defined conclusion of empirical research. IMPLICATIONS: In the light of this understanding, there is a need for "communication," and particularly the methodologies through which it is taught, to reflect these points. Simulation exercises, designed to develop clinical communication, should be clear that there is no single correct way of "talking to patients," no set of behavioral processes which is always effective. It is, in the end, the awareness and wisdom of the doctor, selecting from among a range of available approaches, which is at stake. In addition, methodologies should account for the recognition that awareness comes only from reflection, and that helping medical students and doctors alike to reflect is central to good practice.

Knowledge, skills and beetles: respecting the privacy of private experiences in medical education.

In medical education, we assess knowledge, skills, and a third category usually called values or attitudes. While knowledge and skills can be assessed, this third category consists of 'beetles', after the philosopher Wittgenstein's beetle-in-a-box analogy. The analogy demonstrates that private experiences such as pain and hunger are inaccessible to the public, and that we cannot know whether we all experience them in the same way. In this paper, we claim that unlike knowledge and skills, private experiences of medical learners cannot be objectively measured, assessed, or directly accessed in any way. If we try to do this anyway, we risk reducing them to knowledge and skills-thereby making curriculum design choices based on what can be measured rather than what is valuable education, and rewarding zombie-like student behaviour rather than authentic development. We conclude that we should no longer use the model of representation to assess attitudes, emotions, empathy, and other beetles. This amounts to, first of all, shutting the door on objective assessment and investing in professional subjective assessment. Second, changing the way we define 'fuzzy concepts' in medical education, and stimulating conversations about ambiguous terms. Third, we should reframe the way we think of competences and realize only part of professional development lies within our control. Most importantly, we should stop attempting to measure the unmeasurable, as it might have negative consequences.

Learning to be patient-centred healthcare professionals: how does it happen at university and on clinical placements? A multiple focus group study.

This article was migrated. The article was marked as recommended. Background: Developing patient-centred skills in health professional students relies on their learning experiences at the university and on clinical placements. It is not known what students perceive about their teaching on patient-centredness and their views to develop the curriculum in this aspect. Methods: Multiple focus groups were conducted with students who had experienced a minimum of two clinical placements from Medicine, Physiotherapy, Nursing and Speech and language therapy programs. Thematic analysis was conducted independently by two researchers and then themes were compared and integrated. Findings: Five focus groups with 26 participants with a mean age of 23.8 years contributed to 286 minutes of recorded data. The key findings were that their curriculum focussing on patient-centred skills used artificial methods and teaching focussed largely on biomedical aspects, but, shared modules and specialist training enabled learning. Longer and diverse placements with good role models to emulate, enabled learning. As strategies they suggested reflections and role-modelling were vital along with further interprofessional working, goal-setting and understanding of human psychology. Conclusion: Though the study is limited by its generalisability, strategies suggested by students can be further developed by superimposing them on learning theories. These strategies need to be tested in future studies.

A qualitative study on the use of long-lasting insecticidal nets (LLINs) for the prevention of malaria in the Peruvian Amazon.

BACKGROUND: Malaria is a huge global health burden due to its mortality, morbidity and cost to economies. It is necessary to eliminate the disease in all countries where possible to achieve the World Health Organization target of > 90% reduction by 2030. Successful previous campaigns suggest elimination is feasible in Peru. However, the incidence has recently been rising, focalized to the region of Loreto. Currently, the distribution of long-lasting insecticide-treated nets (LLINs) is a major part of Peru's malaria control strategy, however these may be having a limited effect in Loreto, because of the recent behavioural adaption of the mosquito vector, Anopheles darlingi, to earlier biting times, as well as local perceptions and practices towards LLINs. It was, therefore, necessary to investigate how perceptions, practices and lifestyle factors affect the efficacy of LLINs in Loreto. METHODS: Qualitative research was carried out in 5 rural communities along the Iquitos-Nauta Road in Loreto, which have increased exposure and have received nets in a distribution scheme prior to the study. Twenty semi-structured interviews as well as observations of the bed nets were conducted in participants' homes, using a topic guide. Thematic content analysis was used to produce the findings. RESULTS: All participants viewed malaria prevention as a high priority, and the use of bed nets was deeply embedded in the culture. They expressed preference for LLINs over traditional-type nets. However there were too few LLINs distributed, participants did not maintain the nets correctly, washed them too frequently and did not repair holes. The earlier mosquito biting times were also problematic. Additionally, poor housing construction and proximity to mosquito breeding sites further increased transmission. CONCLUSION: The positive findings in attitudes of the respondents can be used to improve malaria control in these communities. Interventions providing education on effective LLIN use should be implemented. A change in strategy away from vector control methods is also necessary, as these do not provide long-term protection due to the adaptability of An. darlingi. Interventions focusing on parasite control are recommended, and socio-economic factors which increase malaria risk should be addressed.

Patient-centred orientation of students from different healthcare disciplines, their understanding of the concept and factors influencing their development as patient-centred professionals: a mixed methods study.

BACKGROUND: A patient-centred approach to care is increasingly the mandate for healthcare delivery. There is a need to explore how health professional students develop patient-centred attributes. This study aims to understand the extent of patient-centred orientations of health professional students, their perceptions and factors influencing their adoption of the approach. METHODS: The study used a cross-sectional, parallel mixed methods design combining a survey using the Patient-Practitioner Orientation Scale (PPOS) followed by focus groups with medical, nursing, physiotherapy and speech and language therapy students. Data included students' age, gender, programme, and placements experienced. Pearson's chi squared and the non-parametric equivalent Kruskal-Wallis H test were done to test for differences in demographics for appropriate variables. One-way ANOVA or Welch test was done to explore differences in PPOS scores. Regression analysis was done to test the influence of the demographic variables on PPOS scores. Data from focus groups were coded, categorised and organised under themes appropriate to the research aims. RESULTS: Of the 211 complete responses, significant differences were observed between medical and physiotherapy students in total PPOS scores, (MD -8.11 [95% CI -12.02 - 4.20] p = 0.000), Caring component (MD -4.44 [95% CI - 6.69, - 2.19] p = 0.000) and Sharing component (MD -3.67 [95% CI -6.12 -1.22] p = 0.001). The programme in which students were enrolled i.e. Medicine and SALT were the only indicators of higher PPOS total scores (F = 4.6 Df 10,69; p = 7.396e-06) and caring scores (F = 2.164 Df 10, 69 p = 0.022). Focus groups revealed that students perceived patient-centredness as holistic yet individualised care through establishing a partnership with patient. They identified that their student status, placement pressures, placement characteristics especially mentoring influenced their development of patient-centred attributes. CONCLUSION: This study highlights the fact that the pressures of training in the National Health Service affects the development of students' patient-centred orientation. There is a need for further work to explore aspects related to mentor training, for the development of patient-centred attributes, in a curricular framework structured on students' needs from this study.

Understanding professional development: Case studies of remedial support.

This study reports on work undertaken by the Interactive Studies Unit (ISU), University of Birmingham. A total of 727 doctors were referred to the ISU for one-to-one remedial support in a variety of non-clinical areas between 2010 and 2018. The close-in scrutiny which one-to-one support offers provides an opportunity to study and reflect on such issues as values and professionalism, which are notoriously difficult to define or reach objective judgments about. There are fundamental difficulties, in particular, in inferring underlying values from an individual's behavior. The basic taxonomy of referrals the ISU works with, and which echoes those developed elsewhere, considers problems as being at the level of the self, interactions with others, or working in an institutional or societal context. Six common generic problems are identified, and presented and discussed as generic cases. These are designed to be representative of the complex manner in which behavior and values interact, and problems at the three levels above impinge on each other. All cases are accompanied by details of suggested educational activities.

Learning from patients: trainers' use of narratives for learning and teaching.

BACKGROUND: There is a growing interest in how doctors learn from narratives about individual cases, reflected, for example, in the use of e-portfolios. AIM: This study aimed to evaluate how GP trainers conceptualised 'learning from patients', and what use they currently made of narrative recounts in training. DESIGN & SETTING: Thematic analysis (TA) and corpus-linguistic (CL) analysis, with data collected from a convenience sample of trainers in the UK, Ireland, and Spain. METHOD: GP trainers in the three settings were contacted, and volunteers recruited (22 in UK, 24 in Ireland, and 16 in Spain). Volunteers were interviewed and asked to offer a narrative about 'a patient you learned from' and whether they used narratives as a training device. RESULTS: There were no differences between settings. Trainers described an engaged and personal relationship with patients. They described learning about themselves, the human condition, and about how to live and die well. Their narratives were structured in various ways. At times, they led to precise conclusions: at times, they were perceived as meaningful, but resisting analysis. As regards teaching through narrative, it was reported as commonly used, but present practice appears ad hoc rather than planned. DISCUSSION: The lack of difference between settings suggests a degree of commonality about how trainers perceive learning and teaching in the areas explored, but cannot be generalised further. The level of personal engagement was more than anticipated, and suggests the label 'doctor-patient relationship', as the term is used, may not be adequate to describe the nature of some interactions.

Is the practice of goal-setting for patients in acute stroke care patient-centred and what factors influence this? A qualitative study.

OBJECTIVE: To explore whether goal-setting for rehabilitation with acute stroke survivors is patient-centred and identify factors which influence the adoption of patient-centredness in goal-setting practice. SETTING: Acute stroke unit in a large teaching hospital in England. PARTICIPANTS: Patients with stroke who had no cognitive or significant communication problems and health care professionals who had a significant engagement with an individual patient were approached for participation. METHOD: Multiple qualitative methods were used. Perceptions and beliefs about patient-centredness, within the context of goal-setting, were collected from patients and corresponding professionals using qualitative semi-structured interviews. Adoption of patient-centred behaviour was triangulated using analysis of patient records and observation of team meetings related to participating patients. DATA ANALYSIS: Interview transcripts and field notes were coded, clustered under categories and descriptively summarised. Additionally, data from patients' documents were summarised. These summaries were then mapped on to an a-priori frame work of patient-centredness from which further interpretative themes were derived. RESULTS: Seven patients and seven health-care professionals participated. Goal-setting was not consistently patient-centred as evidenced by a) incongruities between patients and professionals in setting, communicating and prioritising of goals and b) dysfunctional therapeutic relationships. The factors that influenced patient-centred goal-setting were both professional and patient beliefs and attributes, work-culture, practice model, limitations in knowledge and systems that disempowered both professionals and patients. CONCLUSION: It may be possible to infer that current local practice of goal-setting was inadequately patient-centred. Further research is required to identify strategies to overcome these challenges and to develop patient-centred goal-setting methods.

Receptionist rECognition and rEferral of Patients with Stroke (RECEPTS): unannounced simulated patient telephone call study in primary care.

BACKGROUND: Stroke is a leading cause of morbidity and mortality. Timely recognition and referral are essential for treatment. AIM: To examine the ability of receptionists in general practices to recognise symptoms of stroke and direct patients to emergency care. DESIGN AND SETTING: Unannounced simulated patient telephone calls and prospective cross-sectional survey study in general practices in the Birmingham and Solihull area. METHOD: A total of 52 general practices participated in a total of 520 simulated telephone calls, with 183 receptionists completing questionnaires. Logistic regression analyses were used to examine likelihood of referral for immediate care by ease of vignette recognition and number of common stroke symptoms present. RESULTS: General practice receptionists correctly referred 69% of simulated calls for immediate care. Calls classed as 'difficult' to recognise were less likely to be immediately referred. Compared with 'easy' calls: 'difficult' calls odds ratio (OR) 0.15, 95% confidence interval (CI) = 0.08 to 0.26; 'moderate' calls OR 0.55, 95% CI = 0.32 to 0.92. Similarly, calls including one or two 'FAST' symptoms were less likely to be referred immediately (compared with three FAST symptoms: one symptom OR 0.30, 95% CI = 0.13 to 0.72; two symptoms OR 0.35, 95% CI = 0.15 to 0.83). CONCLUSION: General practice receptionists refer patients with stroke for immediate care when they present with several symptoms; however, they are less likely to refer patients presenting with only one symptom or less common symptoms of stroke. Optimum management of acute stroke in primary care requires interventions that improve receptionists' knowledge of lesser-known stroke symptoms.

Receptionist rECognition and rEferral of PaTients with Stroke (RECEPTS) study - protocol of a mixed methods study.

BACKGROUND: As the first point of contact for patients and witnesses of stroke, General Practice receptionists can be instrumental in deciding the urgency of clinical contact. Despite the considerable complexity of this task, reception staff are not clinically trained. Minimising the time taken to access thrombolysis is crucial in acute stroke as treatment must be initiated within 4.5 hours of the onset, and the earlier the better, to achieve the best outcomes. Research suggests that patients who first contact their General Practice following the onset of stroke symptoms are less likely to receive thrombolysis, in part due to significant delays within Primary Care.This study therefore aims to understand the role of General Practice receptionists, with particular interest in receptionist's ability to recognise people who may be suffering from a stroke and to handle such patients as a medical emergency. METHODS: The Receptionist rECognition and rEferral of PaTients with Stroke (RECEPTS) study will be a Primary Care based mixed methods study. 60 General Practices in the West Midlands will be recruited. Each practice will receive 10 unannounced simulated patient telephone calls, after the 10 calls questionnaires will be administered to each receptionist. These will examine the behaviour of receptionists towards patients presenting in Primary Care with stroke symptoms, and their knowledge of stroke symptoms. An embedded qualitative study will use interviews and focus groups to investigate the views of General Practice staff on the receptionists' role in patient referral and whether training in this area would be helpful. DISCUSSION: The results of the RECEPTS study will have important implications for providers of Primary Care. The study will establish current practice in UK primary care in terms of General Practice receptionists' knowledge of the presentation and appropriate referral of those who may be suffering a stroke. It will highlight training needs and how such training might be best delivered.

A systematic review and thematic synthesis of qualitative studies on maternal emergency transport in low- and middle-income countries.

BACKGROUND: Most maternal deaths are preventable with emergency obstetric care; therefore, ensuring access is essential. There is little focused information on emergency transport of pregnant women. OBJECTIVES: The literature on emergency transport of pregnant women in low- and middle-income countries (LMICs) was systematically reviewed and synthesized to explore current practices, barriers, and facilitators for transport utilization. SEARCH STRATEGY: MEDLINE, EMBASE, BNI, Cochrane Library, CINAHL, African Index Medicus, ASSIA, QUALIDATA, RHL, and Science Citation Index (inception to April 2012) were searched without language restriction. SELECTION CRITERIA: Studies using qualitative methodology and reporting on emergency transportation in LMICs were included. DATA COLLECTION AND ANALYSIS: Thematic framework and synthesis through examination and translation of common elements were used to analyze and synthesize the data. MAIN RESULTS: Twenty-nine articles were included. Eight major themes were identified: time for transport; transport options; geography; local support; autonomy; culture; finance; and ergonomics. Key issues were transport availability; transport speed; terrain; meteorology; support; dependence for decision making; cultural issues; cost; and lack of safe, comfortable positioning during transport. CONCLUSION: Themes should be appreciated within local contexts to illuminate barriers and facilitators. Potential solutions include motorcycle ambulance programs, collaboration with taxi services, community education, subsidies, and vehicle maintenance.

"If it helps..." the use of microarray technology in prenatal testing: patient and partners reflections.

The objective was to gain insight into the experiences of women and their partners diagnosed with a fetal abnormality on prenatal ultrasound examination and receiving genetic testing including microarray. Twenty-five semi-structured interviews were performed with women +/- their partners after receiving the results of prenatal genetic testing. Framework analysis was performed to elicit themes and subthemes. Five main themes were recognized; diagnosis, genetic testing, family and support, reflections of the treatment received and emotions. Our results showed that women recall being told about QFPCR for trisomy 13, 18, and 21 but often no further testing. Women expected the conventional karyotype and microarray result would be normal following a normal QFPCR result. There were frequent misconceptions by couples regarding aspects of counseling/testing. Communication of variants of unknown (clinical) significance (VOUS) presents a particularly difficult challenge. Good clear communication by health care professionals is paramount. When counseling women and their partners for fetal chromosomal testing it should be reinforced that although the most common, trisomy 13, 18, and 21 only account for some of the chromosomal changes resulting in abnormal scan findings. Couples should have literature to take home summarizing scan anomalies and reinforcing information about genetic testing.

Student-patient communication during physical examination.

BACKGROUND: Communication during the physical examination has been understudied. Explicit, evidence-based guidance is not available as to the most effective content or process of communication while performing physical examination, or indeed how to teach this to medical students. The objective of this exploratory study was to explore how medical students communicate with patients when performing a physical examination in the absence of formal teaching on how to communicate in this situation. METHODS: We recorded 15 senior UK medical students as they performed physical examinations with real patients in general practice situations. The transcriptions were analysed for linguistic functions to identify the use of different categories of utterances. RESULTS: Student utterances fell into four categories: minimising language; using positive evaluative language; repeating the patient; and stating intentions or explanations and requesting consent. Students would often preface an explanation or action by phrases showing 'togetherness', by using 'we' rather than 'you'. They also used linguistic 'hedges' to minimise the impact of an utterance. DISCUSSION: Senior medical students speak very little during the physical examination. When they do, they use a taxonomy of utterances that reflects those reported in doctor-patient interactions. Identifying how medical students communicate when carrying out the physical examination is the first step in planning how to best teach specific communication skills. Further work is needed to identify how best to explore communication during physical examination, and how this is taught and learned.

Module evaluation: a comparison of standard evaluation with nominal group technique.

Teaching and learning practice in higher education (HE) should incorporate educational evaluation, both for the purpose of external and internal quality assurance and to monitor and improve the student experience. Methods used to evaluate education vary, but the majority of literature on course evaluation is based on quantitative surveys of the learner experience. One alternative to survey evaluation is 'nominal group technique' (NGT), which has been used with some success in curriculum development. This multi-method study aimed to (1) compare the nature and quality of data gathered using NGT with standard written questionnaires, (2) assess the usefulness of the feedback for an individual teacher and institution and (3) consider the appropriateness and feasibility of widespread use. Both the standard written questionnaire and NGT generated data on similar topics. The structured nature of the questionnaire tended to generate short answers which were similar to the results of the NGT ranking exercise. However, in contrast to the questionnaire data, the NGT discussion phase allowed in-depth exploration and interrogation of students' views. Whilst the specific data gathered via NGT are unlikely to be useful for quality assurance purposes within an institution, since they is not easily comparable, they can provide teachers with in-depth information on how to improve the learning experience and improve the efficacy of teaching. It is likely that NGT evaluation will be particularly useful when evaluating new courses, identifying problems in poorly performing courses, and identifying good practice in high-performing courses. Institutional investment in selective NGT evaluation may be more feasible than routine use.

The simulation game: an analysis of interactions between students and simulated patients.

CONTEXT: Institutional interactions are often asymmetrical in that the professional has more control over the conversation. It is difficult to say who the professional is in simulated consultations between simulated patients (SPs) and medical students because these feature a real (educational) institutional context and a simulated (medical) institutional context. This study describes this asymmetry and makes educational recommendations based on the description. METHODS: One hundred assessed conversations between SPs and Year 3 students were transcribed and analysed using discourse analysis (DA). We aimed to find linguistic patterns in predefined parts of the conversations (questions, topic initiations, openings, closings) that might suggest conversational dominance. RESULTS: The SP is conversationally more dominant, despite performing the role of the patient, in that he or she asks more direct questions, is more likely to initiate topics, is more likely not to follow topic changes by students, and closes the consultation. The student is likely to follow topics initiated by the SP and to seek permission to pre-close the consultation. CONCLUSIONS: The apparently greater dominance of the SP indicates that the simulated consultation differs from the doctor-patient consultation in certain key aspects. It is in that sense unrealistic. We argue, however, that 'realism' ought not to be a goal of simulated consultation and that what matters is that such consultations are sufficiently realistic for their educational purpose. We discuss the educational implications that follow from this.

When the business of sharing treatment decisions is not the same as shared decision making: A discourse analysis of decision sharing in general practice.

Although shared decision making (SDM) in general practice continues to be promoted as a highly desirable means of conducting consultations it is rarely observed in practice. The aim of this study is to identify the discursive features and conversational strategies particular to the negotiation and sharing of treatment decisions in order to understand why SDM is not yet embedded into routine practice. Consultations from Scottish general practices were examined using discourse analysis. Two themes were identified as key components for when the doctor and the patient were intent on sharing decisions: the generation of patient involvement using first-person pronouns, and successful and unsuccessful patient requesting practices. This article identifies a number of conversational activities found to be successful in supporting doctors' agendas and reducing their responsibility for decisions made. Doctor's use of 'partnership talk' was found to minimize resistance and worked to invite consensus rather than involvement. The information from this study provides new insight into the consultation process by identifying how treatment decisions are arrived at through highlighting the complexities involved. Notably, shared decision making does not happen with the ease implied by current models and appears to work to maintain a biomedical 'GP as expert' approach rather than one in which the patient is truly involved in partnership. We suggest that further research on the impact of conversational activities is likely to benefit our understanding of shared decision making and hence training in and the practice of SDM.