Caregiver Burden, Stress, and Relationship Cohesion Among Self-Identified Caregivers of Children with Pediatric Acute-Onset Neuropsychiatric Syndrome.

Objective: Children with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) experience sudden onset neuropsychiatric symptoms after infection or other triggers. Symptoms range from mild to severe, potentially lasting days, weeks, months, or longer. Exacerbation-related functional decline presents in many aspects of daily life, generally accompanied by family stress and caregiver burden. We sought to investigate the relationship between severity of PANS symptoms and caregiver burden/stress and the relationship between severity of PANS symptoms and degree of caregiver/child cohesion. Methods: This cross-sectional online study surveyed caregivers recruited from PANS-related social media support sites. The Pediatric Acute Neuropsychiatric Symptom Scale - Parent Version (PNSS) measured current severity. Caregiver Burden Inventory (CBI) and Caregiver Self-Assessment Questionnaire (CSAQ) assessed caregiver burden/stress. Inclusion of Other in the Self (IOS) scale determined caregiver-perceived current and desired cohesion with their child(ren) with PANS. Results: Of the 216 respondents 79.6% exceeded CBI threshold indicating need for respite in adult care receiver populations. On the CSAQ, 72.9% expressed high distress, 80.5% reported feeling overwhelmed, and 58.1% reported crying spells, meeting cutoffs for support/respite used in adult care receiver populations. Most caregivers reported not having the desired degree of cohesion with their child on the IOS (85.5%). Parents of children with more severe PNSS symptoms fared significantly worse on all measures (CBI: H = 57.83; CSAQ: F = 29.26; IOS: H = 38.04; p < 0.001 for all). Content analysis of comments revealed five themes: (1) severe caregiver and/or family emotional distress and trauma; (2) caregivers wondering what happened to their child; (3) lack of awareness and support among health and education professionals; (4) relationship strain with family, friends, and significant others; and (5) financial and/or legal struggles because of their child's diagnosis. Conclusion: There is strong need for support and respite for children with PANS and their families. Long-term effects including posttraumatic stress symptoms among family members should be studied.

The importance of developing meaningfulness and manageability for resilience in rural doctors.

INTRODUCTION: Retention of rural doctors is a problem in many countries. A previous study has identified resilience as a factor associated with longer retention. However, this needs a deeper study to understand what local and personal factors are at play. Studies suggest resilience can be developed during training. We propose that a better understanding of factors associated with resilience might assist in training students for rural practice and increase retention. AIM: This study aimed to understand the differences in resilience development between the more and the less resilient rural doctors. A secondary purpose was to identify how to assist this developmental process through health professional education. METHODS: This study employed a mixed-method design and was part of a more extensive study aiming to develop rural doctors' resilience in a low-resource setting. A prior survey assessed rural doctors' resilience levels. This study sampled high-level and low-level resilience participants to be interviewed. A total of 22 rural doctors participated in the individual semi-structured interviews. The interviews were analyzed qualitatively based on Richardson's Resilience Model and the six resilience dimensions looking for factors that explained high or low resilience. RESULTS: Two important themes emerged during the qualitative analysis: 'meaningfulness' and 'manageability.' The different responses of high and low-resilient participants can be explained through cases. CONCLUSIONS: The participants' perceived meaningfulness and manageability of the stressor determine the responses. We suggest that teachers may better construct students' resilience by focussing on assisting them in finding meaning and developing a sense of manageability.

Developing Personal Resilience Questionnaire for rural doctors: an indigenous approach study in Indonesia.

BACKGROUND: Resilience is recognized as a critical component of well-being and is an essential factor in coping with stress. There are issues of using a standardized resilience scale developed for one cultural population to be used in the different cultural populations. This study aimed to create a specific measurement scale for measuring doctors' resilience levels in the rural Indonesian context. METHOD: A total of 527 rural doctors and health professional educators joined this study (37 and 490 participants in the pilot studies and the survey, respectively). An indigenous psychological approach was implemented in linguistic and cultural adaptation and validation of an existing instrument into the local Indonesian rural health context. A combined method of back-translation, committee approach, communication with the original author, and exploratory qualitative study in the local context was conducted. The indigenous psychological approach was implemented in exploring the local context and writing additional local items. RESULT: The final questionnaire consisted of six dimensions and 30 items with good internal consistency (Cronbach's α ranged 0.809-0.960 for each dimension). Ten locally developed items were added to the final questionnaire as a result of the indigenous psychological approach. CONCLUSION: An indigenous psychological approach may enrich the linguistic and cultural adaptation and validation process of an existing scale.

Personal resilience and rural doctors retention: a study in Indonesia.

INTRODUCTION: Retaining the health workforce in rural areas is a global problem. Job dissatisfaction or work-related distress are among the factors that drive doctors to leave rural places. Resilience has been recognised as a key component of wellbeing and is associated with better satisfaction with life. Building personal resilience has the benefits of lowering vulnerability to work-related adversity. This study examined the association between rural doctors' personal resilience and the duration of rural practice. METHODS: This cross-sectional study was set in a rural province in Indonesia. A total sampling procedure was implemented. A total of 528 participants responded to an online survey. The survey tool measured six dimensions of a resilience profile (determination, endurance, adaptability, recuperability, comfort zone and life calling) and collected personal data such as date of birth, practice location and duration of rural practice experience. These participants were classified into four groups: intern, general (GP) with 10 years experience. The data were analysed quantitatively using Oneway analysis of variance (ANOVA). RESULTS: Doctors with longer durations of rural experience showed higher resilience levels in four of the dimensions of personal resilience: endurance, adaptability, recuperabilit­y and comfort zone. Among those four dimensions, endurance and comfort zone showed significant differences between groups with >10 years of difference in rural experience (p<0.05). The other two dimensions, determination and life calling, showed fluctuations across groups with different rural durations. CONCLUSION: This study provides a preliminary result for understanding the relationship between personal resilience and rural doctor retention. It suggests that resilience is partly associated with rural doctor retention. Further studies are needed to examine the causal relationship between resilience and retention.

Leasing a medical curriculum: What's it worth?

Introduction: The early part of this century saw an unprecedented growth in number and size of Australian medical schools. There was some partnering of the new schools with existing programs. Griffith, Deakin and Curtin Universities leased an established curriculum from Flinders University. Nature and rationale for curriculum leasing: The new schools had short startup times and leasing a curriculum enabled them to appoint key staff, develop facilities and meet accreditation requirements in a timely way. However, the lease arrangements were costly and the curriculum was largely determined before the Dean and key staff appointments. Outcomes of leasing: There was differential adoption of the leased curriculum. The first two years of the courses at Flinders were transferred with little change. The final two years of predominantly clinical studies were developed differently. This is explained through Michael Fullan's work on context in educational change. The context of the clinical years of the courses involved negotiations with local health services and other schools using those health services. The advantage of the leasing arrangements was that the new schools could proceed through early development and accreditation, while having time and opportunity to negotiate a clinical curriculum that engaged local health services and fulfilled the new schools' missions.

Expectations of rural community-based medical education: a case study from Thailand.

INTRODUCTION: Thailand has recognised and sought to remedy rural medical workforce shortages. The Collaborative Project to Increase Production of Rural Doctors (CPIRD) has improved rural workforce recruitment through publicly funding medical school places for students with rural backgrounds. However, challenges in rural retention continue. CPIRD is seeking to develop a Thai rural community-based medical education (RCBME) program in the southern region of Thailand to improve preparation for rural practice and rural medical retention rates. Prospective stakeholder consultations will allow the understanding of expectations and concerns of stakeholders required for successful RCBME implementation. This study aims to explore stakeholders' expectations of the Southern Thai RCBME initiative. METHODS: A qualitative case study comprised a purposive sample of students, clinical educators, policymakers, rural health professionals and local community stakeholders, all likely to be involved in a new RCBME program in Songkhla Province, Thailand. Individual semi-structured interviews were audiotaped, transcribed in Thai and coded using Worley's symbiosis framework. Following this, text and quotes used in the initial analysis were translated into English, discussed and reanalysed for emergent themes across the framework. RESULTS: A total of 21 participants contributed RCBME stakeholder perspectives. They demonstrated expectations and concerns in each of the relationship axes of the symbiosis model including the clinical, institutional, social and personal axes. Three major themes emerged from the data that integrated stakeholder perspectives on the implication of RCBME in Thailand. These themes were a dramatic shift in Thai medical education paradigm, seeing rural practice as a future career, and collaboration to improve education and health in rural services. CONCLUSION: This study comprehensively describes Thai stakeholder expectations of RCBME and demonstrates that, although some principles of RCBME are universal, context does influence the expectations and capacity of stakeholders to contribute to RCBME. Prospective formal stakeholder engagement is recommended to ensure successful implementation of new educational innovations.

Stakeholder views of rural community-based medical education: a narrative review of the international literature.

CONTEXT: Rural community-based medical education (RCBME), in which medical student learning activities take place within a rural community, requires students, clinical teachers, patients, community members and representatives of health and government sectors to actively contribute to the educational process. Therefore, academics seeking to develop RCBME need to understand the rural context, and the views and needs of local stakeholders. OBJECTIVES: The aim of this review is to examine stakeholder experiences of RCBME programmes internationally. METHODS: This narrative literature review of original research articles published after 1970 utilises Worley's symbiosis model of medical education as an analysis framework. This model proposes that students experience RCBME through their intersection with multiple clinical, social and institutional relationships. This model seeks to provide a framework for considering the intersecting relationships in which RCBME programmes are situated. RESULTS: Thirty RCBME programmes are described in 52 articles, representing a wide range of rural clinical placements. One-year longitudinal integrated clerkships for penultimate-year students in Anglosphere countries were most common. Such RCBME enables students to engage in work-integrated learning in a feasible manner that is acceptable to many rural clinicians and patients. Academic results are not compromised, and a few papers demonstrate quality improvement for rural health services engaged in RCBME. These programmes have delivered some rural medical workforce outcomes to communities and governments. Medical students also provide social capital to rural communities. However, these programmes have significant financial cost and risk student social and educational isolation. CONCLUSIONS: Rural community-based medical education programmes are seen as academically acceptable and can facilitate symbiotic relationships among students, rural clinicians, patients and community stakeholders. These relationships can influence students' clinical competency and professional identity, increase graduates' interest in rural careers, and potentially improve rural health service stability. Formal prospective stakeholder consultations should be published in the literature.

Assessing tomorrow's learners: in competency-based education only a radically different holistic method of assessment will work. Six things we could forget.

In this paper we are challenging six traditional notions about assessment that are unhelpful when designing 'assessment for learning'-programmes for competency-based education. We are arguing for the following: Reductionism is not the only way to assure rigour in high-stakes assessment; holistic judgements can be equally rigorous. Combining results of assessment parts only because they are of the same format (like different stations in an OSCE) is often not defensible; instead there must be a logically justifiable combination. Numbers describe the quality of the assessment. Therefore, manipulating the numbers is usually not the best way to improve its quality. Not every assessment moment needs to be a decision moment, disconnecting both makes combining summative and formative functions of assessment easier. Standardisation is not the only route to equity. Especially with diverse student groups tailoring is more equitable than standardisation. The most important element to standardise is the quality of the process and not the process itself. Finally, most assessment is too much focussed on detecting deficiencies and not on valuing individual student differences. In competency-based education--especially with a focus on learner orientation--this 'deficiency-model' is not as well aligned as a 'differences-model'.

Urban community based medical education - general practice at the core of a new approach to teaching medical students.

BACKGROUND: The benefits of community based medical education for both students and teachers are becoming increasingly clear. Rural programs offering year-long general practice based clinical training for medical students are well established and highly successful. Urban general practice teaching is currently more likely to be based on short term placements. OBJECTIVE: To describe a new model for urban community based medical education - the Onkaparinga Clinical Education Program - and to discuss its impact on general practitioners, community based specialists and other stakeholders. DISCUSSION: New approaches have been used to successfully translate rural community based medical education models to the urban setting. There is significant potential for urban community based medical education to be extended if adequate support and funding is available. Programs that allow students to access the rich patient care environment of community practice in urban areas can be rewarding for all involved.

Outcomes of longitudinal integrated clinical placements for students, clinicians and society.

CONTEXT: Longitudinal integrated clerkships (LICs) have been widely implemented in both rural and urban contexts, as is now evident in the wealth of studies published internationally. This narrative literature review aims to summarise current evidence regarding the outcomes of LICs for student, clinician and community stakeholders. METHODS: Recent literature was examined for original research articles pertaining to outcomes of LICs. RESULTS: Students in LICs achieve academic results equivalent to and in some cases better than those of their counterparts who receive clinical education in block rotations. Students in LICs are reported to have well-developed patient-centred communication skills, demonstrate understanding of the psychosocial contributions to medicine, and report more preparedness in higher-order clinical and cognitive skills in comparison with students in traditional block rotations (TBRs). Students in LICs take on increased responsibility with patients and describe having more confidence in dealing with ethical dilemmas. Continuity of supervision reportedly facilitates incremental knowledge acquisition, and supervisors provide incrementally progressive feedback. Despite early disorientation regarding the organising of their learning, students feel well supported by the continuity of student-preceptor relationships and value the contributions made by these. Students in LICs living and working in rural areas are positively influenced towards primary care and rural career choices. DISCUSSION: A sound body of knowledge in the field of LIC research suggests it is time to move beyond descriptive or exploratory research that is designed to justify this new educational approach by comparing academic results. As the attributes of LIC alumni are better understood, it is important to conduct explanatory research to develop a more complete understanding of these findings and a foundation for new theoretical frameworks that underpin educational change. CONCLUSIONS: Longitudinal integrated clerkships are now recognised as representing credible and effective pedagogical alternatives to TBRs in medical education.

The context of clinical teaching and learning in Australia.

Gaining clinical experience for an extended period of time in teaching hospitals is one of the enduring strengths of medical education. Teaching hospitals have recently faced significant challenges, with increasing specialisation of services and workload pressures reducing clinical learning opportunities. New clinical teaching environments have been established in Australia, particularly in rural and regional areas; these are proving to be ideal contexts for student learning. The new clinical teaching environments have shown the importance of developing symbiotic relationships between universities and health services. Symbiotic clinical learning is built around longitudinal, patient-based learning emphasising priority health concerns. The symbiotic framework provides a basis for reconstructing clinical teaching in teaching hospitals so th@they continue to play a vital role in Australian medical education, with additional clinical experience provided by primary care and community, rural and regional hospitals.

Teaching clinical skills in musculoskeletal medicine: the use of structured clinical instruction modules.

OBJECTIVE: To assess student evaluation, satisfaction, and examination outcomes for a new method of teaching musculoskeletal (MSK) medicine clinical skills, structured clinical instruction modules (SCIM), and to compare with the outcomes of a traditional method of teaching clinical skills (small group bedside tutorials). METHODS: Year 2 students in a 4 year graduate medical school were taught using the method of bedside senior registrar teaching, supplemented by outpatient attendances in 1997 and by SCIM in 2000. All students in 1997 and 2000 were debriefed at the end of each unit of clinical skills teaching for student feedback on their teaching experience using a standardized questionnaire. At the end of the academic year, all students underwent an objective structured clinical examination (OSCE) in clinical skills that included rheumatology (hand examination) and orthopedic surgery (knee examination) stations. The effect of the method of teaching on the students' performance in the rheumatology (hand) and orthopedic surgery (knee) stations was analyzed. RESULTS: Sixty-seven students were taught clinical skills and completed the OSCE in 1997 and 78 students were taught clinical skills by SCIM and completed the OSCE in 2000. The teaching of orthopedics using traditional methods was poor, but there was no difference in satisfaction between traditional methods of teaching and SCIM for orthopedic surgery and rheumatology. There was no statistically significant difference in the performance of students in the hand OSCE stations in 2000 compared to the same station in 1997. There was a small but statistically significant difference in the performance of students in 1997 and 2000 in the knee station, the 1997 students performing better in this station. CONCLUSION: The SCIM is an effective method of teaching clinical skills in MSK medicine, comparable with patient partners and traditional registrar based bedside teaching methods, but it is less resource intensive.