Effectiveness of a rural longitudinal integrated clerkship in preparing medical students for internship.

BACKGROUND: We interviewed graduates from the first two cohorts of a postgraduate medical program that had a senior year longitudinal integrated clerkship (LIC) in a practice setting in rural New South Wales, Australia to determine how well their training prepared them to be junior doctors (3-4 years after graduation), and what aspects of that training they thought were particularly useful. METHODS: In-depth interviews. RESULTS: Fourteen junior doctors were interviewed. Participants reported feeling well prepared in ability to develop close relationships with clinical supervisors, good clinical and procedural skills, ability to work autonomously and work in teams, knowledge of health systems, ability to ensure self-care, and professionalism. Consensus view was that a rural placement was an excellent way to learn medicine for a variety of reasons including relationships with clinicians, less competition for access to patients, and opportunities to extend their clinical skills and act up to intern level. CONCLUSION: The advantages we found in the training these junior doctors received which prepared them well for internship were integral both to the longitudinal, unstructured placement, and to the fact that it was carried out in a rural area. The two aspects of these placements appear to act synergistically, reinforcing the learning experience.

Defining professionalism in medical education: a systematic review.

INTRODUCTION: We undertook a systematic review and narrative synthesis of the literature to identify how professionalism is defined in the medical education literature. METHODS: Eligible studies included any articles published between 1999 and 2009 inclusive presenting viewpoints, opinions, or empirical research on defining medical professionalism. RESULTS: We identified 195 papers on the topic of definition of professionalism in medicine. Of these, we rated 26 as high quality and included these in the narrative synthesis. CONCLUSION: As yet there is no overarching conceptual context of medical professionalism that is universally agreed upon. The continually shifting nature of the organizational and social milieu in which medicine operates creates a dynamic situation where no definition has yet taken hold as definitive.

Mycoplasma genitalium incidence, organism load, and treatment failure in a cohort of young Australian women.

BACKGROUND: Mycoplasma genitalium (MG) is an emerging sexually transmitted infection (STI) that is potentially associated with reproductive tract sequelae in women. This study aimed to estimate MG incidence and treatment failure and provide estimates of organism load in infection. METHODS: 1110 women aged 16-25 years were recruited from primary care clinics in Australia. Women were tested for MG at baseline, 6 months, and 12 months, and MG organism load was measured by quantitative polymerase chain reaction (PCR). MG-positive cases were screened for MG 23S ribosomal RNA (rRNA) gene point mutations shown to confer azithromycin resistance using high-resolution melt following PCR. RESULTS: MG incidence rate was 1.3 per 100 person-years (n=14; 95% confidence interval [CI], .8-2.3); women reporting 3 or more sex partners in the last 12 months had an increased rate of incident infection (rate ratio [RR], 5.1; 95% CI, 1.3-19.6]). There were 3 cases of MG reinfection (0.8 per 100 person-years [95% CI, .1-.9]. Organism load was higher for prevalent than incident infection (P=.04). There were 3 cases of treatment failure (9.4% [95% CI, 2.0-25.0]); organism load was higher in cases with treatment failure than in successfully treated cases (P<.01). An MG 23S rRNA mutation was detected in 5 cases (3 cases of treatment failure and 2 successfully treated). CONCLUSIONS: Although MG incidence was relatively low, testing should be recommended for women considered to be at increased risk based on sexual history. Our results also suggest that organism load might be important in azithromycin treatment failure.

"They liked it if you said you cried": how medical students perceive the teaching of professionalism.

OBJECTIVE: To discover what Australian medical students think about the way professionalism is taught in their medical curriculum. DESIGN, PARTICIPANTS AND SETTING: Qualitative study including five focus groups between 2 June 2010 and 30 September 2010, comprised of medical students from both undergraduate and postgraduate entry programs who were in the last 1-2 years of the medical program and had undertaken rural longitudinal integrated clinical placements. RESULTS: The five focus groups ran for a total of 5.5 hours. Participants (16 women and 24 men; mean age, 26 years [range 23-32 years]) expressed a low regard for the ways in which professionalism had been taught and assessed in their learning programs. They "gamed the system", giving assessors the results on reflective writing assignments that they believed would gain them a pass. They considered experiential learning - observing good professional practice - to be the best way (some view it as the only way) to learn professionalism and consolidate what they learned, and formed their individual mental model of professionalism through group reflection with their peers in medical school. CONCLUSIONS: While students will always be critical of their curriculum, the universal negative views we captured indicate that current teaching would benefit from review. We suggest a less didactic approach in early years, with more evaluation and feedback from students to assure relevance; an emphasis on true reflection, as opposed to guided reflections linked to overformalised requirements; and more attention devoted to role-modelling and mentoring in the clinical years of training.

Teaching professionalism in medical education: a Best Evidence Medical Education (BEME) systematic review. BEME Guide No. 25.

INTRODUCTION: We undertook a systematic review to identify the best evidence for how professionalism in medicine should be taught. METHODS: Eligible studies included any articles published between 1999 and 2009 inclusive. We reviewed papers presenting viewpoints and opinions as well as empirical research. We performed a comparative and thematic synthesis on all papers meeting inclusion criteria in order to capture the best available evidence on how to teach professionalism. RESULTS: We identified 217 papers on how to teach professionalism. Of these, we determined 43 to be best evidence. Few studies provided comprehensive evaluation or assessment data demonstrating success. As yet, there has not emerged a unifying theoretical or practical model to integrate the teaching of professionalism into the medical curriculum. DISCUSSION: Evident themes in the literature are that role modelling and personal reflections, ideally guided by faculty, are the important elements in current teaching programmes, and are widely held to be the most effective techniques for developing professionalism. While it is generally held that professionalism should be part of the whole of a medical curriculum, the specifics of sequence, depth, detail, and the nature of how to integrate professionalism with other curriculum elements remain matters of evolving theory.

Rural placements are effective for teaching medicine in Australia: evaluation of a cohort of students studying in rural placements.

INTRODUCTION: Medical education in Australia is increasingly delivered through longitudinal placements in general practice and other community settings. Early meaningful exposure to patients has been shown to improve the transition from medical student to junior doctor. This study examines the experience of the first year cohort of the University of Western Sydney (UWS) Medical School long-term rural placement students. Results have been placed in the context of other published results for rural training schemes, comparing and contrasting the present results to those of others. METHODS: Students undertaking a rural placement in their final year of the UWS medical program (n = 21) participated in a mixed methods evaluation. Students filled out a quantitative survey, modified from a validated instrument, and also participated in a focus group. Class ranking of students, and changes over the time of their placement, were also examined. RESULTS: Overall, students were very pleased with their rural experience, both clinically and socially. Students found the rural experience more comprehensive than they had expected. They considered that they had a stronger learning experience in most aspects than they expect they would have received in a metropolitan area. The smaller realm of the medical world in a rural area was considered an advantage in providing more hands-on experience and more interprofessional team approaches to healthcare provision. It was also considered a drawback by some that more advanced cases of all kinds were sent out of the area to metropolitan hospitals. Between their ranking in the end of Year 3 examination and the examination in the middle of Year 5, during which period students undertook their year-long placement, 14 of 22 students increased their class rank while two experienced no change and six decreased their class rank. Overall, the rural cohort advanced 4.2 places compared to their urban-placed peers. CONCLUSIONS: The present results confirm that rural placements have come into their own in Australia. Curriculum content regarding Aboriginal health issues should emphasise the complexity of culture and range of living conditions that makes up Aboriginal Australia and avoid a 'deficit-based perspective' that emphasises extreme cases over routine presentations. Taken together, the results reported by Australian medical schools now offering long-term rural placements suggest that rural long-term placements are at least as effective, and may even be more effective, than metropolitan hospital placements as an effective means of providing clinical education to medical students in their senior years.

'The difference in determinants of Chlamydia trachomatis and Mycoplasma genitalium in a sample of young Australian women'.

BACKGROUND: Differences in the determinants of Chlamydia trachomatis ('chlamydia') and Mycoplasma genitalium (MG) genital infection in women are not well understood. METHODS: A cohort study of 16 to 25 year old Australian women recruited from primary health care clinics, aimed to determine chlamydia and MG prevalence and incidence. Vaginal swabs collected at recruitment were used to measure chlamydia and MG prevalence, organism-load and chlamydia-serovar a cross-sectional analysis undertaken on the baseline results is presented here. RESULTS: Of 1116 participants, chlamydia prevalence was 4.9% (95% CI: 2.9, 7.0) (n = 55) and MG prevalence was 2.4% (95% CI: 1.5, 3.3) (n = 27). Differences in the determinants were found - chlamydia not MG, was associated with younger age [AOR:0.9 (95% CI: 0.8, 1.0)] and recent antibiotic use [AOR:0.4 (95% CI: 0.2, 1.0)], and MG not chlamydia was associated with symptoms [AOR:2.1 (95% CI: 1.1, 4.0)]. Having two or more partners in last 12 months was more strongly associated with chlamydia [AOR:6.4 (95% CI: 3.6, 11.3)] than MG [AOR:2.2 (95% CI: 1.0, 4.6)] but unprotected sex with three or more partners was less strongly associated with chlamydia [AOR:3.1 (95%CI: 1.0, 9.5)] than MG [AOR:16.6 (95%CI: 2.0, 138.0)]. Median organism load for MG was 100 times lower (5.7 × 104/swab) than chlamydia (5.6 × 106/swab) (p < 0.01) and not associated with age or symptoms for chlamydia or MG. CONCLUSIONS: These results demonstrate significant chlamydia and MG prevalence in Australian women, and suggest that the differences in strengths of association between numbers of sexual partners and unprotected sex and chlamydia and MG might be due to differences in the transmission dynamics between these infections.

Maximising retention in a longitudinal study of genital Chlamydia trachomatis among young women in Australia.

BACKGROUND: Cohort studies are an important study design however they are difficult to implement, often suffer from poor retention, low participation and bias. The aims of this paper are to describe the methods used to recruit and retain young women in a longitudinal study and to explore factors associated with loss to follow up. METHODS: The Chlamydia Incidence and Re-infection Rates Study (CIRIS) was a longitudinal study of Australian women aged 16 to 25 years recruited from primary health care clinics. They were followed up via the post at three-monthly intervals and required to return questionnaires and self collected vaginal swabs for chlamydia testing. The protocol was designed to maximise retention in the study and included using recruiting staff independent of the clinic staff, recruiting in private, regular communication with study staff, making the follow up as straightforward as possible and providing incentives and small gifts to engender good will. RESULTS: The study recruited 66% of eligible women. Despite the nature of the study (sexual health) and the mobility of the women (35% moved address at least once), 79% of the women completed the final stage of the study after 12 months. Loss to follow up bias was associated with lower education level [adjusted hazard ratio (AHR): 0.7 (95% Confidence Interval (CI): 0.5, 1.0)], recruitment from a sexual health centre as opposed to a general practice clinic [AHR: 1.6 (95% CI: 1.0, 2.7)] and previously testing positive for chlamydia [AHR: 0.8 (95% CI: 0.5, 1.0)]. No other factors such as age, numbers of sexual partners were associated with loss to follow up. CONCLUSIONS: The methods used were considered effective for recruiting and retaining women in the study. Further research is needed to improve participation from less well-educated women.

Where do students in the health professions want to work?

BACKGROUND: Rural and remote areas of Australia are facing serious health workforce shortages. While a number of schemes have been developed to improve recruitment to and retention of the rural health workforce, they will be effective only if appropriately targeted. This study examines the factors that most encourage students attending rural clinical placements to work in rural Australia, and the regions they prefer. METHODS: The Careers in Rural Health Tracking Survey was used to examine the factors that most influence medical, nursing and allied health students' preference for practice locations and the locations preferred. RESULTS: Students showed a preference for working in large urban centres within one year, but would consider moving to a more rural location later in life. Only 10% of students surveyed said they would never work in a rural community with a population of less than 10,000. Almost half the sample (45%) reported wanting to work overseas within five years. The type of work available in rural areas was found to be the factor most likely to encourage students to practice rurally, followed by career opportunities and challenge. CONCLUSION: The decision to practise rurally is the result of a complex interaction between a number of factors including ethnicity, discipline, age and sex, among others. Incentives that aim to entice all students to rural practice while considering only one of these variables are likely to be inadequate.

Twelve tips on rural medical placements: what has worked to make them successful.

Providing undergraduate and post-graduate rural training opportunities aids rural medical recruitment. Medical schools that provide rural educational placements, and the communities that host those placements, must give serious consideration to the structure and supports required to ensure both quality and enjoyment of rural placements. This paper presents tips for success gleaned from the results of experience in providing rural placement opportunities to medical students throughout their medical school experience.

Improving vaccination cold chain in the general practice setting.

BACKGROUND: This study compared temperature control in different types of vaccine storing refrigerators in general practice and tested knowledge of general practice staff in vaccine storage requirements. METHODS: Temperature data loggers were set to serially record the temperature within vaccine refrigerators in 28 general practices, recording at 12 minute intervals over a period of 10 days on each occasion. A survey of vaccine storage knowledge and records of divisions of general practice immunisation contacts were also obtained. RESULTS: There was a significant relationship between type of refrigerator and optimal temperature, with the odds ratio for bar style refrigerator being 0.005 (95% CI: 0.001-0.044) compared to the purpose built vaccine refrigerators. Score on a survey of vaccine storage was also positively associated with optimal storage temperature. DISCUSSION: General practices that invest in purpose built vaccine refrigerators will achieve standards of vaccine cold chain maintenance significantly more reliably than can be achieved through regular cold chain monitoring and practice supports.

21st century medical education.

Australian universities provide good examples of how to meet the growing challenges to the training of doctors that have resulted from information overload in traditional curricula, new models of care, including multidisciplinary team dynamics, and the rigours of evidence-based practice.

The researcher development program: how to extend the involvement of Australian general practitioners in research?

CONTEXT: This article reviews the Researcher Development Program (RDP) component of the Australian Government's Primary Health Care Research, Evaluation, and Development (PHC RED) strategy, examining critical aspects of program performance and suggesting strategies that might increase the involvement of rural GPs in research. ISSUE: Primary health care research capacity can only be built by providing sustainable, dedicated funding and a dedicated redistribution of workload from practice to research. The PHC RED funds and program supports only provide incentives to redirect existing capacity within primary health care from patient care to research for the time during which incentives are in place, generally as a part-time funded position for less than one-year's duration. The one-year time constraint is the most serious impediment to the success of the program. There is no formal provision for the continuing status of clinician/researchers. Continuation depends on the capacity of the mentor agencies, academic departments of general practice or university departments of rural health, to continue to support them, and on the time they can make available from their practice. Existing measures of program success, published research and new knowledge incorporated into practice settings, are too ambitious for researchers given a one-year time frame, working part time. Clinician/researchers have a demonstrated willingness to devote time to developing and answering a research question, but often lack the time and administrative support to get through the processes required, including ethics application and writing for publication. LESSONS LEARNED: A better way to capture success of the RDP program might be through a multi-objective composite set of measures of research performance that captures different types of outputs, with weighting factors assigned to different measures of research output. Development of peer-review panels to replace or augment annual reporting to assess the progress of PHC RED programs might also serve both to measure success and to promote collaborative ventures. Small scale research projects are more conducive to practising GPs than randomised controlled trials or large scale observational studies. Smaller projects can still lead to important discoveries and improvements to the healthcare system. Examples include guideline development, descriptive studies, and small-number analytical epidemiological studies. In order to engage the rural primary care community in redirecting clinical time to research, the needs of clinicians must be met, as well as those of funders, academic mentors and collaborators. Structures and systems that can be developed through PHC RED, including research networks, will determine whether efforts to increase research in primary-care settings succeed and are sustainable. Sustainable networks need sustainable funding.

Decision criteria in health professionals choosing a rural practice setting: development of the Careers in Rural Health Tracking Survey (CIRHTS).

INTRODUCTION: Rural background and training have previously been found to increase the likelihood of rural practice. However, practitioners of many health professions remain in shortage in rural and remote Australia. This study builds on previous work in that it includes medical, nursing and allied health professions, considers the role of the health professional's family in employment decisions, and includes a broader array of factors influencing employment preference and the preferred location of practice. The survey also examines when students might work in a rural area. METHOD: The survey was designed after an extensive review of relevant literature and existing surveys, consultation with rural clinicians, and piloting with students. Approximately 500 students per year are anticipated to complete the survey while on placement at the Northern Rivers University Department of Rural Health, New South Wales, Australia, and will be contacted annually for at least 10 years. RESULTS: The Careers in Rural Health Tracking Survey questions both students and their spouses about employment preferences and related family factors. It contains questions about the size of towns respondents would be willing to work in, and when they would consider working there. It also asks in which regions of Australia students and partners would be prepared to work. CONCLUSIONS: This study aims to expand knowledge of the factors that encourage or discourage health professionals from practising in rural areas. Information about the time dimension in decision-making, areas most likely to face shortages, and about the types of clinicians most likely to work in certain regions, will be crucial when developing initiatives to attract new graduates to rural practice.

Teaching by videoconference: a commentary on best practice for rural education in health professions.

This article offers a primer on how to get started in videoconferencing, focusing on practical approaches to technical and protocol issues. The technical capabilities of videoconferencing systems, linked with initiatives supporting greater rural access to broadband, means videoconferencing is expanding rapidly as a health education tool. Forethought allows the purchase of the most appropriate equipment, reducing costs overall and increasing the functionality of the system. Adherence to simple matters, including etiquette, ensures the experience is enjoyable as well as educational. Consideration should be given to the role of videoconferencing in expanding the social as well as academic opportunities for rural clinicians and students. Videoconferencing is a useful adjunct to traditional educational delivery modes, and can enable quality education opportunities that would be prohibitive due to time, travel, and cost constraints.

The role of the public in the management of public health risks.

OBJECTIVE: To critique current models of public involvement in the management of public health risks. METHODS: Two case studies are used to highlight the challenges of contemporary practice. RESULTS: Current models often result in affected communities having perceptions of risk that conflict with those responsible for risk management. This can lead to ineffective decision making. CONCLUSIONS: Involving the public throughout the risk assessment and risk management process may lessen conflict and result in better decisions. IMPLICATIONS: Those responsible for responding to public health risks should aim for transparent processes that highlight assumptions and uncertainties, and involve the public wherever possible.

What do young women think about having a chlamydia test? Views of women who tested positive compared with women who tested negative.

OBJECTIVE: To determine young women's experience of having a chlamydia (Chlamydia trachomatis) test as part of a chlamydia incidence study, and to determine how women who tested positive during the study experienced having a test compared with the experience of women who always tested negative. METHODS: Women in an Australian chlamydia incidence study were tested at 3- to 6-monthly intervals during a 12-month period. At the final stage of the study, the women completed a questionnaire about how they felt about testing positive or how they anticipated they might feel about testing positive if they only tested negative. Questions about future sexual behaviour and testing were included. RESULTS: The questionnaire was completed by 872 out of 1116 (78%) women, including 67 women who tested positive. Many women (75%) felt anxious when having a chlamydia test but women who tested positive were less concerned about their future health (61% v. 81%, P<0.01), were less concerned about their partner's reactions (62% v. 79%, P<0.01) and were more likely to discuss their diagnosis with other people (57% v. 36%, P<0.01). CONCLUSIONS: The participants in the study were pleased to have been tested and supported a screening program. Women who tested positive were less concerned about having a positive result than women who tested negative anticipated they might be. IMPLICATIONS: Clinicians need to be aware that having a chlamydia test can cause anxiety in young women and for a screening program to be successful, this must be addressed.

Prevalent and incident bacterial vaginosis are associated with sexual and contraceptive behaviours in young Australian women.

BACKGROUND: To determine prevalence and incidence of bacterial vaginosis (BV) and risk factors in young sexually-active Australian women. METHODS: 1093 women aged 16-25 years were recruited from primary-care clinics. Participants completed 3-monthly questionnaires and self-collected vaginal smears 6-monthly for 12-months. The primary endpoint was a Nugent Score = 7-10 (BV) and the secondary endpoint was a NS = 4-10 (abnormal flora [AF]). BV and AF prevalence estimates and 95% confidence intervals (95%CI) were derived, and adjusted odds ratios (AOR) calculated to explore epidemiological associations with prevalent BV and AF. Proportional-hazards regression models were used to examine factors associated with incident BV and AF. RESULTS: At baseline 129 women had BV [11.8% (95%CI: 9.4-14.2)] and 188 AF (17.2%; 15.1-19.5). Prevalent BV was associated with having a recent female partner [AOR = 2.1; 1.0-4.4] and lack of tertiary-education [AOR = 1.9; 1.2-3.0]; use of an oestrogen-containing contraceptive (OCC) was associated with reduced risk [AOR = 0.6; 0.4-0.9]. Prevalent AF was associated with the same factors, and additionally with >5 male partners (MSP) in 12-months [AOR = 1.8; 1.2-2.5)], and detection of C.trachomatis or M.genitalium [AOR = 2.1; 1.0-4.5]. There were 82 cases of incident BV (9.4%;7.7-11.7/100 person-years) and 129 with incident AF (14.8%; 12.5-17.6/100 person-years). Incident BV and AF were associated with a new MSP [adjusted rate ratio (ARR) = 1.5; 1.1-2.2 and ARR = 1.5; 1.1-2.0], respectively. OCC-use was associated with reduced risk of incident AF [ARR = 0.7; 0.5-1.0]. CONCLUSION: This paper presents BV and AF prevalence and incidence estimates from a large prospective cohort of young Australian women predominantly recruited from primary-care clinics. These data support the concept that sexual activity is strongly associated with the development of BV and AF and that use of an OCC is associated with reduced risk.

Chlamydia trachomatis incidence and re-infection among young women--behavioural and microbiological characteristics.

BACKGROUND: This study aimed to estimate rates of chlamydia incidence and re-infection and to investigate the dynamics of chlamydia organism load in prevalent, incident and re-infections among young Australian women. METHODS: 1,116 women aged 16 to 25 years were recruited from primary care clinics in Australia. Vaginal swabs were collected at 3 to 6 month intervals for chlamydia testing. Chlamydia organism load was measured by quantitative PCR. RESULTS: There were 47 incident cases of chlamydia diagnosed and 1,056.34 person years of follow up with a rate of 4.4 per 100 person years (95% CI: 3.3, 5.9). Incident infection was associated with being aged 16 to 20 years [RR = 3.7 (95%CI: 1.9, 7.1)], being employed [RR = 2.4 (95%CI: 1.1, 4.9)] and having two or more new sex partners [RR = 5.5 (95%CI: 2.6, 11.7)]. Recent antibiotic use was associated with a reduced incidence [RR:0.1 (95%CI: 0.0, 0.5)]. There were 14 re-infections with a rate of 22.3 per 100 person years (95%CI: 13.2, 37.6). The median time to re-infection was 4.6 months. Organism load was higher for prevalent than incident infections (p<0.01) and for prevalent than re-infections (p<0.01). CONCLUSIONS: Chlamydia is common among young women and a high proportion of women are re-infected within a short period of time, highlighting the need for effective partner treatment and repeat testing. The difference in organism load between prevalent and incident infections suggests prevalent infection may be more important for ongoing transmission of chlamydia.

Doctors trading places: the Isolated Practitioner Peer Support Scheme.

We describe the outcomes of a practice exchange in which an isolated general practitioner from a remote region traded work and living arrangements with a rural group practice GP. An exchange can provide an opportunity for mid- and senior-career professionals to refresh their outlook on their careers. Involving the rural medical workforce in practice exchanges can enable the development of peer networks that can improve retention of isolated practitioners in Australia. A fresh experience in a new setting can provide opportunities for practitioners to improve practice management and sharpen their clinical skills. Uprooting families and preparing homes for unfamiliar visitors add stress to doctors and their families on exchange. Patients in isolated practices could feel concerned that they may lose their doctor as a result of an exchange. In this instance, the benefits far outweighed the difficulties.