HIV understanding, experiences and perceptions of HIV-positive men who have sex with men in Amazonian Peru: a qualitative study.

BACKGROUND: HIV-related incidence and mortality is increasing across Peru, with highest mortality rates recorded in the Amazonian region of Loreto. This epidemic is concentrated in men who have sex with men, a population with 14% HIV treatment adherence despite free national provision. This study investigates barriers and facilitators to following healthcare advice through experiences and perceptions of HIV-positive men who have sex with men and healthcare professionals in Loreto. METHODS: Twenty qualitative interviews with HIV-positive men who have sex with men and one focus group with HIV-specialist healthcare professionals were conducted in Loreto, January-February 2019. Interviews were transcribed per verbatim. Thematic content analysis and deviant case analysis were used. RESULTS: A culture of isolation and discrimination was identified, propagated by poor public knowledge surrounding HIV transmission and treatment. Employment potential was hampered and 7/20 patients had suicidal thoughts post-diagnosis. Barriers to care included: shame, depression, travel cost/times, a preference for traditional plant-based medicine and side-effects of antiretroviral therapy. Facilitators included: education, family and clinic support, disease acceptance and lifestyle changes. CONCLUSION: More effective, focussed community education and workplace discrimination investigations are recommended to reduce stigma and increase adherence to treatment in this population.

Improving outcomes for multi-drug-resistant tuberculosis in the Peruvian Amazon - a qualitative study exploring the experiences and perceptions of patients and healthcare professionals.

BACKGROUND: Management for multi-drug-resistant tuberculosis (MDR-TB) is challenging and has poor patient outcomes. Peru has a high burden of MDR-TB. The Loreto region in the Peruvian Amazon is worst affected for reasons including high rates of poverty and poor healthcare access. Current evidence identifies factors that influence MDR-TB medication adherence, but there is limited understanding of the patient and healthcare professional (HCP) perspective, the HCP-patient relationship and other factors that influence outcomes. A qualitative investigation was conducted to explore and compare the experiences and perceptions of MDR-TB patients and their dedicated HCPs to inform future management strategies. METHOD: Twenty-six, semi-structured in-depth interviews were conducted with 15 MDR-TB patients and 11 HCPs who were purposively recruited from 4 of the worst affected districts of Iquitos (capital of the Loreto region). Field notes and transcripts of the two groups were analysed separately using thematic content analysis. Ethics approval was received from the Institutional Research Ethics Committee, Department of Health, Loreto, and the University of Birmingham Internal Research Ethics Committee. RESULTS: Four key themes influencing patient outcomes emerged in each participant group: personal patient factors, external factors, clinical factors, and the HCP-patient relationship. Personal factors included high standard patient and population knowledge and education, which can facilitate engagement with treatment by encouraging belief in evidence-based medicine, dispelling belief in natural medicines, health myths and stigma. External factors included the adverse effect of the financial impact of MDR-TB on patients and their families. An open, trusting and strong HCP-patient relationship emerged as a vitally important clinical factor influencing of patient outcomes. The results also provide valuable insight into the dynamic of the relationship and ways in which a good relationship can be fostered. CONCLUSIONS: This study highlights the importance of financial support for patients, effective MDR-TB education and the role of the HCP-patient relationship. These findings add to the existing evidence base and provide insight into care improvements and policy changes that could improve outcomes if prioritised by local and national government.

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.

Beyond 'health and safety' - the challenges facing students asked to work outside of their comfort, qualification level or expertise on medical elective placement.

BACKGROUND: On elective students may not always be clear about safeguarding themselves and others. It is important that placements are safe, and ethically grounded. A concern for medical schools is equipping their students for exposure to and response to uncomfortable and/or unfamiliar requests in locations away from home, where their comfort and safety, or that of the patient, may be compromised. This can require legal, ethical, and/or moral reasoning on the part of the student. The goal of this article is to establish what students actually encounter on elective, to inform better preparing students for safe and ethical medical placements. We discuss the implications of our findings, which are arguably applicable to other areas of graduate training, e.g. first medical roles post-qualification. METHOD: An anonymised survey exploring clinical and ethical dilemmas on elective was issued across 3 years of returning final year elective medical students. Questions included the prevalence and type of potentially unsafe scenarios encountered, barriers to saying 'no' in unsafe situations, perceived differences between resource poor and developed world settings and the degree to which students refused or consented to participation in events outside of the 'norms' of their own training experience. RESULTS: Three hundred seventy-nine students participated. 45% were asked to do something "not permissible" at home. 27% were asked to do something they felt "uncomfortable" with, often an invasive clinical task. Half asked to do something not usually permissible were "comfortable". 48% felt it more acceptable to bypass guidelines in developing settings. 27% refused an offer outside their experience. CONCLUSION: Of interest are reasons for "going along with" uncomfortable invitations, e.g. "emergency", self-belief in 'capability' and being 'more qualified' than host-personnel. This "best pair of hands available" merits scrutiny. Adverse scenarios were not exclusive to developing settings. We discuss preparing students for decision-making in new contexts, and address whether 'home' processes are too inflexible to prepare students for 'real' medical life? Ethical decision-making and communicating reluctance should be included in elective preparation.

Preventing malaria in the Peruvian Amazon: a qualitative study in Iquitos, Peru.

BACKGROUND: In Peru, despite decades of concerted control efforts, malaria remains a significant public health burden. Peru has recently exhibited a dramatic rise in malaria incidence, impeding South America's progress towards malaria elimination. The Amazon basin, in particular the Loreto region of Peru, has been identified as a target for the implementation of intensified control strategies, aiming for elimination. No research has addressed why vector control strategies in Loreto have had limited impact in the past, despite vector control elsewhere being highly effective in reducing malaria transmission. This study employed qualitative methods to explore factors limiting the success of vector control strategies in the region. METHODS: Twenty semi-structured interviews were conducted among adults attending a primary care centre in Iquitos, Peru, together with 3 interviews with key informants (health care professionals). The interviews focussed on how local knowledge, together with social and cultural attitudes, determined the use of vector control methods. RESULTS: Five themes emerged. (a) Participants believed malaria to be embedded within their culture, and commonly blamed this for a lack of regard for prevention. (b) They perceived a shift in mosquito biting times to early evening, rendering night-time use of bed nets less effective. (c) Poor preventive practices were compounded by a consensus that malaria prevention was the government's responsibility, and that this reduced motivation for personal prevention. (d) Participants confused the purpose of space-spraying. (e) Participants' responses also exposed persisting misconceptions, mainly concerning the cause of malaria and best practices for its prevention. CONCLUSION: To eliminate malaria from the Americas, region-specific strategies need to be developed that take into account the local social and cultural contexts. In Loreto, further research is needed to explore the potential shift in biting behaviour of Anopheles darlingi, and how this interacts with the population's social behaviours and current use of preventive measures. Attitudes concerning personal responsibility for malaria prevention and long-standing misconceptions as to the cause of malaria and best preventive practices also need to be addressed.

Recommendations for undergraduate medical electives: a UK consensus statement.

INTRODUCTION: Many doctors, across grades and specialities, supervise or advise students and juniors undertaking elective placements. Electives form part of medical curricula on a worldwide scale. The Medical Schools Council (MSC) Electives Committee in the UK identified a gap in the current literature in relation to provision of comprehensive recommendations for the design and management of undergraduate elective programmes. Electives afford many known benefits for medical and other health care students, but the context, and risks (impacting potentially on patient, public and student well-being) are usually different from those associated with 'home' clinical placements. AIM: The aim is to share experiences and good practice within UK Medical Schools, and inform and inspire others involved with similar programmes across the globe. METHOD: This paper reports the results of the formation of a sub-group to draft a set of recommendations, drawing on the reported experiences of academic elective leads across all UK schools, and including input from the MSC, and the student group Medsin (to capture the learner voice). The final document was the result of a national consultative process of four iterations. The end document was approved at school level, e.g. by curriculum committee, by each of the participating schools. RECOMMENDATIONS: The recommendations consolidate the experiences of 30 participating UK medical schools. The consultation process generated 17 pre-departure recommendations, seven during elective recommendations, 11 post elective recommendations and a further four recommendations relating to infectious disease. CONCLUSION: We believe developing elective programmes using collective recommendations will provide a basis for a safer and more structured approach to a medical elective without losing the uniqueness and creative experiences valued by participants. Issues relating to undergraduates leaving their home school to experience medicine in a new context or country replicate across sites, so many recommendations will be transferable internationally.

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.

National survey of clinical communication assessment in medical education in the United Kingdom (UK).

BACKGROUND: All medical schools in the UK are required to be able to provide evidence of competence in clinical communication in their graduates. This is usually provided by summative assessment of clinical communication, but there is considerable variation in how this is carried out. This study aimed to gain insight into the current assessment of clinical communication in UK medical schools. METHODS: The survey was sent via e-mail to communication leads who then were asked to consult with all staff within their medical school involved in the assessment of communication. RESULTS: Results were obtained from 27 out of 33 schools (response rate 82%) and a total of 34 courses. The average number of assessments per year was 2.4 (minimum 0, maximum 10). The Objective Structured Clinical Exam (OSCE) was the most commonly used method of assessment (53%). Other assessments included MCQ and workplace based assessments. Only nine courses used a single method of assessment. Issues raised included, logistics and costs of assessing mainly by OSCE, the robustness and reliability of such exams and integration with other clinical skills. CONCLUSIONS: It is encouraging that a variety of assessment methods are being used within UK medical schools and that these methods target different components of clinical communication skills acquisition.

How do United Kingdom (UK) medical schools identify and support undergraduate medical students who 'fail' communication assessments? A national survey.

BACKGROUND: The doctor's ability to communicate effectively (with patients, relatives, advocates and healthcare colleagues) relates directly to health outcomes, and so is core to clinical practice. The remediation of medical students' clinical communication ability is rarely addressed in medical education literature. There is nothing in the current literature reporting a contemporary national picture of how communication difficulties are managed, and the level of consequence (progression implications) for students of performing poorly. This survey aimed to consolidate practices for identifying and processes for managing students who 'fail' communication assessments across all UK medical schools. METHODS: Data were collected via an email survey to all leads for clinical communication in all UK Medical Schools for the UK Council for Clinical Communication in Undergraduate Medical Education. RESULTS: All but two participating Schools reported some means of support and/or remediation in communication. There was diversity of approach, and variance in the level of systemisation adopted. Variables such as individuality of curricula, resourcing issues, student cohort size and methodological preferences were implicated as explaining diversity. Support is relatively ad hoc, and often in the hands of a particular dedicated individual or team with an interest in communication delivery with few Schools reporting robust, centralised, school level processes. CONCLUSIONS: This survey has demonstrated that few Medical Schools have no identifiable system of managing their students' clinical communication difficulties. However, some Schools reported ad hoc approaches and only a small number had a centralised programme. There is scope for discussion and benchmarking of best practice across all Schools with allocation of appropriate resources to support this.

The impact of discussing a sexual history in role-play simulation teaching on pre-clinical student attitudes towards people who submit for STI testing.

Sex, sexuality and sexual health beliefs are individual, impacting on physical and mental health. Sexual history taking is rarely taught in General Practice (GP). However, 'sex' is routinely relevant in this setting. Birmingham students practice discussing sexual history with a simulated-patient in GP. Simulated-patient inclusion in teaching/assessment is well-documented, but no study evaluating the impact of role play on attitudes to people who need STI testing was identified. We aimed to identify whether facilitated simulations featuring a sexual history scenario effected change in students' attitudes towards people who need STI testing. A randomised-controlled-trial was used to compare attitudinal scores between students exposed to an STI role play and a control group who did not receive the role-play teaching until after data capture. There were no significant differences in attitude, either in negative or positive direction, observed between control and intervention groups. Ethnicity was a significant variable, with white-British students self-reporting more positive attitudes. Twenty five percent students admitted personal STI exposure. Again response varied significantly between ethnic groups (the white-British group reporting 4× the exposure). Females reported more positive attitudes than males, most marked in relation to 'willingness to date' someone who admitted to STI testing.

Using standardized patients to assess communication skills in medical and nursing students.

BACKGROUND: A number of recent developments in medical and nursing education have highlighted the importance of communication and consultation skills (CCS). Although such skills are taught in all medical and nursing undergraduate curriculums, there is no comprehensive screening or assessment programme of CCS using professionally trained Standardized Patients Educators (SPE's) in Ireland. This study was designed to test the content, process and acceptability of a screening programme in CCS with Irish medical and nursing students using trained SPE's and a previously validated global rating scale for CCS. METHODS: Eight tutors from the Schools of Nursing and Medicine at University College Cork were trained in the use of a validated communication skills and attitudes holistic assessment tool. A total of forty six medical students (Year 2 of 5) and sixty four nursing students (Year 2/3 of 4) were selected to under go individual CCS assessment by the tutors via an SPE led scenario. Immediate formative feedback was provided by the SPE's for the students. Students who did not pass the assessment were referred for remediation CCS learning. RESULTS: Almost three quarters of medical students (33/46; 72%) and 81% of nursing students (56/64) passed the CCS assessment in both communication and attitudes categories. All nursing students had English as their first language. Nine of thirteen medical students referred for enhanced learning in CCS did not have English as their first language. CONCLUSIONS: A significant proportion of both medical and nursing students required referral for enhanced training in CCS. Medical students requiring enhanced training were more likely not to have English as a first language.

Effects of exposure to mental illness in role-play on undergraduate student attitudes.

BACKGROUND: Education is integral to reducing stigma toward the mentally ill. Medical educators have a key role in delivering education that reduces that stigma. Undergraduate psychiatric training and specific education programs are both effective in reducing stigma. However, many students are exposed to concepts of mental illness at a much earlier stage in their education. No previous study has explored the effect of intervention such as role-play on student attitudinal development. OBJECTIVES: This study's objective was to identify whether undergraduate role-play exercises featuring mental illness influenced development of attitudes toward the mentally ill. METHODS: A randomized controlled trial was used to compare attitudinal scores between students exposed to a mental illness role-play as part of routine teaching and a control group that did not receive the teaching. RESULTS: A total of 332 students provided data. There were no between-group differences for any attitudinal scores, although gender (being female) and experience of mental illness were associated with more positive attitudinal scores. CONCLUSIONS: Single high-intensity routine teaching sessions such as role-play involving metal illness do not influence student attitudes.

UK consensus statement on the content of communication curricula in undergraduate medical education.

CONTEXT: The teaching and assessment of clinical communication have become central components of undergraduate medical education in the UK. This paper recommends the key content for an undergraduate communication curriculum. Designed by UK educationalists with UK schools in mind, the recommendations are equally applicable to communication curricula throughout the world. OBJECTIVES: This paper is intended to assist curriculum planners in the design, implementation and review of medical communication curricula. The document will also be useful in the education of other health care professionals. Designed for undergraduate education, the consensus statement also provides a baseline for further professional development. METHODS: The consensus statement, based on strong theoretical and research evidence, was developed by an iterative process of discussion between communication skills leads from all 33 UK medical schools conducted under the auspices of the UK Council of Clinical Communication Skills Teaching in Undergraduate Medical Education. DISCUSSION: How this framework is used will inevitably be at the discretion of each medical school and its implementation will be determined by different course designs. Although we believe students should be exposed to all the areas described, it would be impractical to set inflexible competency levels as these may be attained at different stages which are highly school-dependent. However, the framework will enable all schools to consider where different elements are addressed, where gaps exist and how to generate novel combinations of domains within the communication curriculum. It is hoped that this consensus statement will support the development and integration of teaching, learning and assessment of clinical communication.

Simulated patients in the community pharmacy setting. Using simulated patients to measure practice in the community pharmacy setting.

BACKGROUND: Performance measurement and quality of care in community pharmacy settings is problematic because of the lack of formal patient registration and the resultant risk of selection bias. Although simulated patients have been used for teaching and education purposes, particularly in medical settings, their use as a research tool requires exploration in other health settings. The purpose of this paper is to describe how we used simulated patients to measure professional performance of community pharmacy staff. METHOD: Sixty pharmacies participated in a randomised controlled trial (RCT) to evaluate the effectiveness and efficiency of two guideline implementation strategies in the community pharmacy setting. The primary outcome measure for the study was derived from assessment forms completed by simulated patients following covert visits to participating pharmacies. RESULTS: Of the 420 simulated patient visits scheduled, 384 (91%) were completed. Nine visits were reported by pharmacy staff using reply-paid postcards, four of which concurred with known SP visits. Each detected visit was made by a different SP. In a post-intervention survey, 26 (52%) pharmacists stated they had been apprehensive about the use of simulated patients as part of the study, however, 41 (82%) pharmacists agreed that SP visits were an acceptable research method to use in a community pharmacy setting. DISCUSSION: Simulated patients are a feasible method of assessing professional performance in community pharmacy settings and overcome the methodological problems of other measurement methods. Further research is needed to assess the reliability and validity of simulated patients.

Gender as a variable in the assessment of final year degree-level communication skills.

AIM: To investigate possible bias due to gender combination of students, role players and examiners in a high-stakes assessment. SETTING: Valid oral interactive contextualized examinations (VOICEs) is a long-station OSCE-style exam in general practice (GP). At the time of writing it consisted of 65% of the student's final GP mark. METHOD: In the VOICE, students undertake six tasks--four vivas and two role-plays. "Patient" roles are taken by professional role players who work regularly on the undergraduate curriculum. During the role-play, the student's clinical competence is assessed by an observing GP examiner. The communication skills marks are awarded by the role player and the examiner together, by negotiation. Data have been recorded detailing the role player's initial marks, the examiner's initial marks and their final (awarded) agreed marks for 1024 consultations. SAMPLE: 512 final year medical students, 28 role players and 48 examiners. There were no inclusion or exclusion criteria. All those present on exam day became part of the data. RESULTS: There was a significant relationship between gender and performance for some, but not all, stations. Correlations for multiple comparisons removed the significance. Female students perform better across the board than male students. While not always significant, this did affect grading. There was no significant association between the genders of role players and examiners with the question choices. There has been a significant worsening of male results since 1999. Differences exist in the way that pairs of mixed or single genders score students.

Hitting the mark: negotiated marking and performance factors in the communication skills element of the VOICE examination.

INTRODUCTION: Communication skills assessment is complex. Standardised patient use is widespread, but anxiety exists around the use of role players as assessors of competence in high stakes examinations. This study measures the level of agreement between scoring examiners and role players, and considers their influence on each other. Examiner status and question choices are analysed as variables. METHOD: The valid oral interactive contextualised examination (VOICE) is a general practice examination styled as an objective structured clinical examination (OSCE) of six 15-minute stations, which include two role-played consultations with professional role players. The examination candidates are final year medical students. Clinical components are examined by a general practitioner (GP). Communication skills are assessed by these examiners in conjunction with the role players, through a process of negotiation. Descriptive professionalism/attitude bandings are used as percentage-scoring guidelines. Checklists are not used. For this study, the initial (independently) perceived marks of the two scoring groups and their agreed final (awarded) marks were recorded, along with other variables including gender, performance factors, demographics and the nature of the question. Data represents 512 students undertaking 1024 simulated consultations, examined by 28 role players and 46 examiners. Analysis was carried out using SPSS Version 10. RESULTS: Results show that the examination and negotiation process is consistent. Role players have a direct influence on scoring. The examiner's background is a significant variable [F9,1014 = 4.207, P < 0.001]. Students perform less well on questions involving higher degrees of clinical information giving. Question choice is not significant [F30,3039 = 1.397, P=0.074]. DISCUSSION: The variables in the examination do not indicate any discrepancy substantial enough to bias a student's grade. Negotiated marking in this context is considered safe and reliable.