Surgical debridement in long bone chronic osteomyelitis: is wide tumour-like resection necessary?

Aims: The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit. Methods: We analyzed the retrospective record review from 2014 to 2020 of patients with long bone COM. All were managed by multidisciplinary infection team (MDT) protocol. Adequate debridement was employed for all cases, and no case of wide resection was included. Results: A total of 53 patients (54 bones) with median age of 45.5 years (interquartile range 31 to 55) and mean follow-up of 29 months (12 to 59) were included. In all, ten bones were Cierny-Mader type I, 39 were type III, and five were type IV. All patients were treated with single-staged management, except for one (planned two-stage stabilization). Positive microbial cultures grew in 75%. Overall, 46 cases (85%) had resolution of COM after index procedure, and 49 (90.7%) had resolution on last follow-up. Four patients (7%) underwent second surgical procedure and six patients (11%) had complications. Conclusion: We challenge the need for wide tumour-like resection in all cases of COM. Through detailed preoperative evaluation and planning with MDT approach, adequate debridement and local delivery of high concentration of antibiotic appears to provide comparable outcomes versus radical debridement.

Where do rural family medicine residents in Canada train?

OBJECTIVE: To report on contextual variance in the distributed rural family medicine residency programs of 3 Canadian medical schools. DESIGN: A constructivist grounded theory methodology was employed. SETTING: Rural and remote postgraduate family medicine programs at the University of Alberta, the University of British Columbia, and the University of Calgary. PARTICIPANTS: Twenty-six family practice residents were interviewed, providing descriptions of 27 different rural sites and 10 regional sites. METHODS: Interviews were audiorecorded, transcribed verbatim, and thematically analyzed. MAIN FINDINGS: Participants differentiated between main campus academic health science centres; regional referral hub sites; and smaller, rural, and more remote community sites. Participants described major differences between sites in terms of patient, practice, educational, physical, institutional, and social factors. The differences between training sites included variations in learning opportunities; physical challenges related to weather, distance, and travel; and the social opportunities offered. There were also differences in how residents perceived their training sites, both in terms of what they noticed and how they interpreted their observations and experiences. Although there were contextual differences between regional sites, those differences were a lot less than between different smaller rural and remote sites. These differences shaped the learning opportunities available to residents and influenced their well-being. CONCLUSION: Although there may be some similarities between distributed training sites, each training context presents unique challenges and opportunities for the family medicine residents placed there. More attention to the specific affordances of different training contexts is required.

Contextual Competence: How residents develop competent performance in new settings.

INTRODUCTION: Medical education continues to diversify its settings. For postgraduate trainees, moving across diverse settings, especially community-based rotations, can be challenging personally and professionally. Competent performance is embedded in context; as a result, trainees who move to new contexts are challenged to use their knowledge, skills and experience to adjust. What trainees need to adapt to and what that requires of them are poorly understood. This research takes a capability approach to understand how trainees entering a new setting develop awareness of specific contextual changes that they need to navigate and learn from. METHODS: We used constructivist grounded theory with in-depth interviews. A total of 29 trainees and recent graduates from three internal medicine training programmes in Canada participated. All participants had completed at least one community-based rotation geographically far from their home training site. Interviews were recorded, transcribed and anonymised. The interview framework was adjusted several times following initial data analysis. RESULTS: Contextual competence results from trainees' ability to attend to five key stages. Participants had first to meet their physiological and practical needs, followed by developing a sense of belonging and legitimacy, which paved the way for a re-constitution of competence and appropriate autonomy. Trainee's attention to these stages of adaptation was facilitated by a process of continuously moving between using their knowledge and skill foundation and recognising where and when contextual differences required new learning and adaptations. DISCUSSION: An ability to recognise contextual change and adapt accordingly is part of Nussbaum and Sen's concept of capability development. We argue this key skill has not received the attention it deserves in current training models and in the support postgraduate trainees receive in practice. Recommendations include supporting residents in their capability development by debriefing their experiences of moving between settings and supporting clinical teachers as they actively coach residents through this process.

Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail.

INTRODUCTION: High-energy grade III open fractures of tibia are associated with significant complications and generate debate over the ideal fixation method. This study compares the clinical outcomes for circular frame fixation (CFF) vs intramedullary nail fixation (IMF) in grade III open tibial fractures. MATERIALS AND METHODS: Single-centre retrospective study of patients admitted from January 2008 to December 2016. All patients with grade III open diaphyseal tibial fractures (AO 42 A, B, C), treated with either CFF or IMF, were included. The primary outcome was deep bone infection (DBI). Secondary outcomes were delayed or non-union, secondary intervention, and amputation. RESULTS: A total of 48 limbs in 47 patients had CFF, and 25 limbs in 23 patients had IMF. Median time to definitive fixation was significantly longer for CFF at 9 days (IQR 3-13) compared to IMF at 1 day (IQR 0-3.5) (p <0.001). The DBI rate was significantly lower (2 vs 16%) in the CFF group (p = 0.04). There were 14 limbs (29%) with delayed or non-union in the CFF group vs 5 limbs (20%) in the IMF group. In the CFF group, significantly more limbs required bone grafting for delayed or non-union (p = 0.03). However, there was a greater proportion of limbs in the CFF group with segmental fractures or bone loss (46 vs 4%) and these high-energy fracture patterns were associated with secondary bone grafting (p = 0.005), and with delayed or non-union (p = 0.03). A subgroup analysis of patients without segmental fractures or bone loss treated with either CFF or IMF showed no significant difference in secondary bone grafting (p >0.99) and delayed or non-union rates (p = 0.72). Overall, one patient in each group went on to have an amputation. CONCLUSION: Our study found that CFF had a lower rate of DBI compared to IMF. Injuries with high-energy fracture patterns (segmental fractures or bone loss) were more likely to have delayed or non-union and require secondary bone grafting. These factors should be considered when selecting the appropriate method of definitive fixation. HOW TO CITE THIS ARTICLE: Natalwala I, Chuo CB, Shariatmadari I, et al. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2021;16(3):161-167.

Exploring the Contributions of Combined Model Regional Medical Education Campuses to the Physician Workforce.

PURPOSE: Physician shortages and maldistribution, particularly within family medicine, have led many medical schools worldwide to create regional medical campuses (RMCs) for clerkship training. However, Canadian medical schools have developed a number of RMCs in which all years of training (i.e., a combined model that includes both preclerkship and clinical training) are provided geographically separate from the main campus. This study addresses the question: Are combined model RMC graduates more likely to enter postgraduate training in family medicine and rural-focused programs relative to main campus graduates? METHOD: The authors used a quasi-experimental research design and analyzed 2006-2016 data from the Canadian Resident Matching Service (CaRMS). Graduating students (N = 26,525) from 16 Canadian medical schools who applied for the CaRMS match in their year of medical school graduation were eligible for inclusion. The proportions of graduates who matched to postgraduate training in (1) family medicine and (2) rural-focused programs were compared for combined model RMCs and main campuses. RESULTS: Of RMC graduates, 48.4% matched to family medicine (95% confidence interval [CI] = 46.1-50.7) compared with 37.1% of main campus graduates (95% CI = 36.5-37.7; P < .001). Of RMC graduates, 23.9% matched to rural-focused training programs (95% CI = 21.8-25.9) compared with 10.4% of main campus graduates (95% CI = 10.0-10.8; P < .001). Subanalyses ruled out a variety of potentially confounding variables. CONCLUSIONS: Combined model RMCs, in which all years of training take place away from the medical school's main campus, are associated with greater proportions of medical students entering family medicine postgraduate training and rural-focused training programs. These findings should encourage policymakers, health services agencies, and medical schools to continue seeking complements to academic medical center-based medical education.

An international study of trainee-trained transitions: Introducing the transition-to-trained-doctor (T3D) model.

Background: Throughout their careers, doctors and other healthcare professionals experience numerous transitions. When supporting transitions, opportunities for development and learning should be maximized, while stressors having negative impacts on well-being should be minimized. Building on our international data, this study aimed to develop a conceptual model of the trainee-trained transition (i.e. the significant transitions experienced by doctors as they complete postgraduate training moving from trainee/resident status to medical specialist roles).Methods: Employing Multiple and Multidimensional Transitions (MMT) theory and current conceptualizations of clinical context, this study undertook secondary analysis of 55 interviews with doctors from three countries (Netherlands, Cananda and the UK) undergoing trainee-trained transitions.Results: Through this analysis, the Transition-To-Trained-Doctor (T3D) conceptual model has been developed. This model takes into consideration the multiple contexts and multiple domains in which transitions take place.Discussion: This model is significant in that it has several uses and is applicable across countries: to remind doctors, managers and medical educators of the complexity of transitions; to frame and facilitate supportive conversations; and as a basis to teach about transitions.

The regional medical campus model and rural family medicine practice in British Columbia: a retrospective longitudinal cohort study.

BACKGROUND: Regional medical campuses have been implemented across North America to address gaps in the physician workforce. We report findings from a study that examined the association between a combined model of regional medical campuses and students' decision to enter rural family medicine practice. METHODS: In 2004, the University of British Columbia added 2 regional medical campuses, 1 in a large population centre in a rural and coastal context and 1 in a medium-sized population centre in an isolated northern and rural context. Data were extracted from the University of British Columbia's Medical Education Database. Multivariable logistic regression examined the relationship of age, sex, rural background and campus location to students' choice of rural family medicine practice. RESULTS: There was an association between campus location and choice of family medicine versus other specialties. A rural background (odds ratio [OR] 2.59, 95% confidence interval [CI] 1.08-6.21) and training at either of the 2 regional medical campuses (OR 3.24, 95% CI 1.19-8.83 and OR 5.38, 95% CI 2.24-12.91) predicted rural family practice. INTERPRETATION: Choosing to practise family medicine in a rural location was associated with having a rural background and having trained at a regional medical campus. These early results suggest that a combined regional campus model in medical education contributes to the rural family practice workforce.

Working in the dead of night: exploring the transition to after-hours duty.

CONTEXT: Transitions, although often difficult, represent integral components of medical training. New postgraduate trainees (first-year residents) find themselves in an especially challenging transition as they are expected to fulfil both learning and service expectations concurrently. Workplace learning theory has been suggested as a lens through which to understand this unique educational, yet service-oriented, role. This tension may be further amplified overnight when residents are on-call with little to no support. OBJECTIVES: The aims of this study were to explore the transition from medical student to resident with respect to the on-call experience, and to provide theory-based suggestions to enhance learning during this unique transition. METHODS: We conducted an interpretivist qualitative study by interviewing eight medical students and 10 first-year residents from six different specialty training programmes across four academic sites. Each semi-structured interview was transcribed verbatim and anonymised. Resident interview transcripts were initially coded for major themes, after which medical student interview transcripts were coded for consistencies and discrepancies. RESULTS: Four interrelated themes were identified in students' and residents' descriptions of on-call experiences: (i) shift in responsibility; (ii) supervisory support; (iii) contextual conditions, and (iv) clarity of expectations. Generally, students were not able to anticipate the challenges they would face as residents on-call, and residents perceived the transition as sudden with little emphasis placed on learning. CONCLUSIONS: First-year residents face multiple challenges during on-call, which may prevent optimal learning in this setting. These challenges are amplified by the large gap between the respective roles of medical students and residents. We identified promoters of and barriers to effective learning in this environment and, by using workplace learning theory, provide recommendations for how we might be able to enhance medical students' preparation for and first-year residents' learning during experiences of being on-call.

Embracing standardisation and contextualisation in medical education.

CONTEXT: The tensions that emerge between the universal and the local in a global world require continuous negotiation. However, in medical education, standardization and contextual diversity tend to operate as separate philosophies, with little attention to the interplay between them. METHODS: The authors synthesise the literature related to the intersections and resulting tensions between standardization and contextual diversity in medical education. In doing so, the authors analyze the interplay between these competing concepts in two domains of medical education (admissions and competency-based medical education), and provide concrete examples drawn from the literature. RESULTS: Standardization offers many rewards: its common articulations and assumptions promote patient safety, foster continuous quality improvement, and enable the spread of best practices. Standardization may also contribute to greater fairness, equity, reliability and validity in high stakes processes, and can provide stakeholders, including the public, with tangible reassurance and a sense of the stable and timeless. At the same time, contextual variation in medical education can afford myriad learning opportunities, and it can improve alignment between training and local workforce needs. The inevitable diversity of contexts for learning and practice renders any absolute standardization of programs, experiences, or outcomes an impossibility. CONCLUSIONS: The authors propose a number of ways to examine the interplay of contextual diversity and standardization and suggest three ways to move beyond an either/or stance. In reconciling the laudable goals of standardization and the realities of the innumerable contexts in which we train and deliver care, we are better positioned to design and deliver a medical education system that is globally responsible and locally engaged.

Can a complex adaptive systems perspective support the resiliency of the heart failure patient - informal caregiver dyad?

PURPOSE OF REVIEW: A holistic palliative approach for heart failure care emphasizes supporting nonprofessional informal caregivers. Informal caregivers play a vital role caring for heart failure patients. However, caregiving negatively affects informal caregivers' well being, and in turn heart failure patients' health outcomes. This opinion article proposes that complex adaptive systems (CAS) theory applied to heart failure models of care can support the resiliency of the heart failure patient - informal caregiver dyad. RECENT FINDINGS: Heart failure care is enacted within a complex system composed of patients, their informal caregivers and a variety of health professionals. In a national study, we employed a CAS perspective to explore how all parts of the heart failure team function interdependently in emergent and adaptive ways. Salient in our data were the severe vulnerability of elderly heart failure patients and their long-term partners who suffered from a chronic illness. Novel approaches are needed that can quickly adapt and reorganize care when unpredictable disturbances occur in the couples' functional capacity. SUMMARY: The linear protocol-driven care models that shape heart failure guidelines, training and care delivery initiatives do not adequately capture heart failure patients' social environment. CAS is a powerful theoretical tool that can render visible the most vulnerable members of the heart failure team, and incite robust specialized holistic palliative heart failure care models.

What Do Patients Talk About? A Qualitative Analysis of Online Chat Sessions with Health Care Specialists During a "Virtual" Cardiac Rehabilitation Program.

INTRODUCTION: Cardiac rehabilitation programs (CRPs) are effective at reducing cardiovascular disease (CVD) risk, yet attendance in these programs remains low due to geographic constraints. In a previously conducted randomized trial we demonstrated that a virtual CRP (vCRP) delivered over the Internet reduced risk for CVD. The current investigation has reviewed the online chat sessions between participants and healthcare providers (HCP) to describe the content of discussions during the vCRP intervention. MATERIALS AND METHODS: Participants were recruited from two geographically isolated areas in British Columbia, Canada without in-person CRP or a cardiologist serving the area. The vCRP, among other elements, included scheduled one-on-one chat sessions with a dietician, exercise specialist, and nurse to mimic standard CRP consultations. The chat sessions were reviewed for content and themes. Multiple chat sessions between participants and a single care provider were also analyzed to describe how chat content progressed through multiple sessions. RESULTS: A total of 38 participants participated in the vCRP intervention. From the 122 chat sessions between participants and HCP during the vCRP, the main themes identified were Managing Health and Lifestyle, Continuity of Care, and Getting Care from a Distance. Within each theme, sub-themes were also identified. CONCLUSIONS: The vCRP chat sessions fulfilled the role of face-to-face consultations with HCP that are standard in hospital-based CRP and addressed patient concerns, facilitating remote patient-provider interaction and covering topics on exercise, diet, and positive behavior changes to limit risk factors for future heart problems.

The Contextual Curriculum: Learning in the Matrix, Learning From the Matrix.

Changes in the health care landscape over the last 25 years have led to an expansion of training sites beyond the traditional academic health sciences center. The resulting contextual diversity in contemporary medical education affords new opportunities to consider the influence of contextual variation on learning. The authors describe how different contextual patterns in clinical learning environments-patients, clinical and educational practices, physical geography, health care systems, and culture-form a contextual learning matrix. Learners' participation in this contextual matrix shapes what and how they learn, and who they might become as physicians.Although competent performance is critically dependent on context, this dependence may not be actively considered or shaped by medical educators. Moreover, learners' inability to recognize the educational affordances of different contexts may mean that they miss critical learning opportunities, which in turn may affect patient care, particularly in the unavoidable times of transition that characterize a professional career. Learners therefore need support in recognizing the variability of learning opportunities afforded by different training contexts. The authors set out the concept of the contextual curriculum in medical education as that which is learned both intentionally and unintentionally from the settings in which learning takes place. Further, the authors consider strategies for medical educators through which the contextual curriculum can be made apparent and tangible to learners as they navigate a professional trajectory where their environments are not fixed but fluid and where change is a constant.

The Participant Recruitment Outcomes (PRO) study: Exploring contemporary perspectives of telehealth trial non-participation through insights from patients, clinicians, study investigators, and study staff.

BACKGROUND: Telehealth has been proposed as an alternative means to providing traditional modes of care while alleviating the need for participant travel and reducing overall healthcare costs. The purpose of this study was to explore contemporary perspectives of patients and stakeholders regarding non-participation in telehealth trials. METHODS: We undertook a two-phase exploratory qualitative study to understand the reasons behind patient non-participation in telehealth. Data were collected through semi-structured interviews with non-participating patient participants (n = 8) and stakeholders (n = 27) including clinicians, study investigators, and study staff. An analysis of interview data were undertaken and guided by a qualitative descriptive approach. FINDINGS: Patients and stakeholders reported many barriers to telehealth participation including technological barriers, limited understanding of disease, and an understated need for services. Both groups had some overlap in their concerns but also provided unique insights. CONCLUSION: The analysis of study findings revealed perspectives of patients and stakeholders including barriers to participation as well as suggestions for future telehealth initiatives. Further research is needed to explore non-participation including patient readiness to assist in the development of future telehealth programs.

Patients with heart failure and their partners with chronic illness: interdependence in multiple dimensions of time.

BACKGROUND: Informal caregivers play a vital role in supporting patients with heart failure (HF). However, when both the HF patient and their long-term partner suffer from chronic illness, they may equally suffer from diminished quality of life and poor health outcomes. With the focus on this specific couple group as a dimension of the HF health care team, we explored this neglected component of supportive care. MATERIALS AND METHODS: From a large-scale Canadian multisite study, we analyzed the interview data of 13 HF patient-partner couples (26 participants). The sample consisted of patients with advanced HF and their long-term, live-in partners who also suffer from chronic illness. RESULTS: The analysis highlighted the profound enmeshment of the couples. The couples' interdependence was exemplified in the ways they synchronized their experience in shared dimensions of time and adapted their day-to-day routines to accommodate each other's changing health status. Particularly significant was when both individuals were too ill to perform caregiving tasks, which resulted in the couples being in a highly fragile state. CONCLUSION: We conclude that the salience of this couple group's oscillating health needs and their severe vulnerabilities need to be appreciated when designing and delivering HF team-based care.

It's all about relationships : A qualitative study of family physicians' teaching experiences in rural longitudinal clerkships.

INTRODUCTION: The relationship between preceptor and trainee is becoming recognized as a critical component of teaching, in particular in the negotiation of feedback and in the formation of professional identity. This paper elaborates on the nature of the relationships between preceptor and student that evolve in the context of rural longitudinal integrated clerkships (LICs). METHODS: We drew on constructivist grounded theory for the research approach. We interviewed nine LIC family practice preceptors from three sites at one educational institution. We adapted the interview framework based on early findings. We analyzed the data through a constant comparative process. We then drew on concepts of relationship-based learning as sensitizing concepts in a secondary analysis. RESULTS: We constructed three themes from the data. First, preceptors developed trusting professional and personal relationships with students over time. These relationships expanded to include friendship, advocacy, and ongoing contact beyond the clerkship year. Second, preceptors' approach to teaching was anchored in the relationship with an understanding of the individual student. Third, preceptors set learning goals collaboratively with their students, based not only on program objectives, but also with the student as a future physician in mind. DISCUSSION: Our findings suggest that rural family medicine preceptors developed engaged and trusting relationships with their students over time. These relationships imbued all activities of teaching and learning with an individual and personal focus. This orientation may be a key factor in supporting the learning outcomes demonstrated for students studying in rural LICs.

Learning From Patients: Why Continuity Matters.

PURPOSE: Patient continuity, described as the student participating in the provision of comprehensive care of patients over time, may offer particular opportunities for student learning. The aim of this study was to describe how students experience patient continuity and what they learn from it. METHOD: An interpretive phenomenological study was conducted between 2015 and 2016. Seventeen fourth-year medical students were interviewed following a longitudinal clinical placement and asked to describe their experiences of patient continuity and what they learned from each experience. Transcripts were analyzed by iteratively refining and testing codes, using health system definitions of patient continuity as sensitizing concepts to develop descriptive themes. RESULTS: Students described three different forms of patient continuity. Continuity of care, or relational continuity, enabled students to build trusting and professional relationships with their patients. Geographical continuity allowed students to access information about patients from electronic records and their preceptors which allowed students to achieve diagnostic closure and learn to reevaluate their decisions. Students valued the learning that accrued from following challenging patients and addressing challenging decisions over time. Although difficult, these patient continuity experiences led students to critical reflection that was both iterative and deep, leading to intentions for future behavior. CONCLUSIONS: Patient continuity in medical education does not depend solely on face-to-face continuity. Within various patient continuity experiences, following challenging patients and experiencing unanticipated diagnostic and management outcomes trigger critical reflection in students, leading to deep learning.

How and Why Preclerkship Students Set Learning Goals and Assess Their Achievement: A Qualitative Exploration.

PURPOSE: Health professionals are expected to routinely assess their weaknesses, set learning goals, and monitor their achievement. Unfortunately, it is well known that these professionals often struggle with effectively integrating external data and self-perceptions. To know how best to intervene, it is critical that the health professionals community understand the cues students and practitioners use to assess their abilities. Here the authors aimed to gain insights into how and why medical students set learning goals, monitor their progress, and demonstrate their learning. METHOD: In 2012, the authors conducted semistructured interviews with Year 2 students (n = 20), applying an inductive approach to data analysis by iteratively developing, refining, and testing coding structures. RESULTS: Themes were constructed through discussion and consensus: (1) Students were diverse in how they set learning goals, (2) they used a range of approaches to monitor their progress, and (3) they struggled to balance studying for exams with preparation for clinical training. Tensions observed highlight assumptions embedded in medical curricula that can be problematic. CONCLUSIONS: Educators often treat medical students as a cohesive whole, thereby creating a mismatch between assessments that are intended to be formative and information students use to monitor their progress. Despite limited exposure to clinical contexts, goal generation and monitoring often stem from a desire to prepare for clinical practice. In grappling with these tensions, it is important to be mindful that students are individualistic in how they balance their commitment to prepare for clinical work and the need to concentrate on exams.

Ecological theories of systems and contextual change in medical education.

INTRODUCTION: Contemporary medical practice is subject to many kinds of change, to which both individuals and systems have to respond and adapt. Many medical education programmes have their learners rotating through different training contexts, which means that they too must learn to adapt to contextual change. Contextual change presents many challenges to medical education scholars and practitioners, not least because of a somewhat fractured and contested theoretical basis for responding to these challenges. There is a need for robust concepts to articulate and connect the various debates on contextual change in medical education. Ecological theories of systems encompass a range of concepts of how and why systems change and how and why they respond to change. The use of these concepts has the potential to help medical education scholars explore the nature of change and understand the role it plays in affording as well as limiting teaching and learning. METHODS: This paper, aimed at health professional education scholars and policy makers, explores a number of key concepts from ecological theories of systems to present a comprehensive model of contextual change in medical education to inform theory and practice in all areas of medical education. RESULTS: The paper considers a range of concepts drawn from ecological theories of systems, including biotic and abiotic factors, panarchy, attractors and repellers, basins of attraction, homeostasis, resilience, adaptability, transformability and hysteresis. Each concept is grounded in practical examples from medical education. CONCLUSION: Ecological theories of systems consider change and response in terms of adaptive cycles functioning at different scales and speeds. This can afford opportunities for systematic consideration of responses to contextual change in medical education, which in turn can inform the design of education programmes, activities, evaluations, assessments and research that accommodates the dynamics and consequences of contextual change.