Comparison of educational environments in different sized rural hospitals during a longitudinal integrated clerkship in Thailand.

INTRODUCTION: The longitudinal integrated clerkship (LIC) curriculum model focuses on patient-centered care and continuity of clinical and cultural learning between medical students, patients, clinicians, and a system of care. In rural settings, participating medical students are expected to have an interest in rural medicine and an involvement in the community. Many schools in the USA, Canada, and Australia have implemented LICs in undergraduate programs in different ways. However, a few published reports in Asia are available. This is the first report of a modified rural LIC in Thailand. The objective was to assess the educational environment of a rural LIC using the Dundee Ready Education Environment Measure (DREEM) questionnaire and to compare students' response on the basis of year of study and different sizes of hospitals. METHODS: A cross-sectional study was conducted. The study population comprised 75 clinical-year students in 2020. The modified LIC was implemented as part of integrated multidisciplinary rural clerkships for fourth-year students, and for fifth-year students undertaking clinical placements. Clinical clerkships in rural settings took place over 12 weeks for fourth-year students and over 14 weeks for fifth-year students. Practical exposure included the clinical areas of internal medicine, psychiatry, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and family medicine, in outpatient and inpatient settings. The DREEM questionnaire was used to evaluate students' perceptions of learning climate. Data analysis was performed to determine the different size of hospitals and other factors associated with a favorable educational environment. RESULTS: The response rate to the questionnaire was 96%. The overall DREEM score average was 137.7/200. Students' perceptions of learning and of teaching had mean scores of 30.1/48 and 35.7/44, respectively. Students' academic self-perceptions scored 18.7/32. Students' perceptions of atmosphere scored 30.4 of 48, and social self-perceptions scored 18.3/28. The academic subscale had the lowest percentage of scores regarded as confidence in knowledge gain. The factors associated with positive educational environment were staff as principal preceptors and large hospitals. CONCLUSIONS: LIC implementation in a community health system is a model for expanding clinical clerkships. Good infrastructure of the host hospital and enthusiastic preceptors are the key success factors. Staff supervision is essential to encourage student learning, especially in academic environments. Large hospitals have better infrastructure to support learning processes than small hospitals.

Community-based learning enhances doctor retention.

Background: Rural doctor shortage is a problem in many countries. Factors associated with doctor retention were reported such as colleagues, workload, accommodations, transportation, proximity of family and friends, incentives and career path. Rural background recruitment, increasing the quantity of doctor production to supply in rural and remote areas, and regulation are claimed to alleviate doctor scarcity in rural communities. Many programs have been developed, but an imbalance in physician distribution persists. Community-based learning (CBL) is recommended by the WHO to promote doctor retention. The longer contact time of CBL is practical, but it is uncertain that this results in greater retention. The objective of this study is to determine the association between contact time of CBL and retention of doctor with rural background recruitment. Methods: A cohort study was performed. The study population was 10,018 doctors graduated during 2001-2010 and followed up at least to 2014. Of the 10,018 physicians, 2098 doctors (21%) were recruited from rural backgrounds by the Collaborative Project to Increase Production of Rural Doctor (CPIRD). Contact time of CBL was calculated to the proportion of total curricular credit hours. The primary outcome was retention rate in government health-care system over 4 years. Statistical analysis was performed using multiple logistic regression. Results: A total of 5774 doctors (57.6%) were retained in the government health-care system. Higher percentages of CPIRD doctors were retained than normal track (72.1% and 53.8%, P < 0.001), especially in rural hospitals (60.3% and 38.4%, P < 0.001). Based on univariate analysis, CBL was slightly higher in retention than resignation group with statistical significance (2.97% and 2.90%, P = 0.045). Multiple logistic regression results showed that CBL, graduate entry, and geographic location of workplace were significantly associated with retention. Discussion: CBL can enhance doctor retention. It should incorporate meaningful experience such as rural exposure together with classroom teaching to focus concepts and integrating service to the community. Graduate entry and geographic location of workplace also have an impact on decision-making regarding retention.

Infectious causes of encephalitis and meningoencephalitis in Thailand, 2003-2005.

Acute encephalitis is a severe neurologic syndrome. Determining etiology from among ≈100 possible agents is difficult. To identify infectious etiologies of encephalitis in Thailand, we conducted surveillance in 7 hospitals during July 2003-August 2005 and selected patients with acute onset of brain dysfunction with fever or hypothermia and with abnormalities seen on neuroimages or electroencephalograms or with cerebrospinal fluid pleocytosis. Blood and cerebrospinal fluid were tested for >30 pathogens. Among 149 case-patients, median age was 12 (range 0-83) years, 84 (56%) were male, and 15 (10%) died. Etiology was confirmed or probable for 54 (36%) and possible or unknown for 95 (64%). Among confirmed or probable etiologies, the leading pathogens were Japanese encephalitis virus, enteroviruses, and Orientia tsutsugamushi. No samples were positive for chikungunya, Nipah, or West Nile viruses; Bartonella henselae; or malaria parasites. Although a broad range of infectious agents was identified, the etiology of most cases remains unknown.

Clinical Prediction Rule of Drug Resistant Epilepsy in Children.

BACKGROUND AND PURPOSE: Clinical prediction rules (CPR) are clinical decision-making tools containing variables such as history, physical examination, diagnostic tests by developing scoring model from potential risk factors. This study is to establish clinical prediction scoring of drug-resistant epilepsy (DRE) in children using clinical manifestationa and only basic electroencephalography (EEG). METHODS: Retrospective cohort study was conducted. A total of 308 children with diagnosed epilepsy were recruited. Primary outcome was the incidence of DRE. Independent determinants were patient characteristics, clinical manifestations and electroencephalography. CPR was performed based on multiple logistic regression. RESULTS: The incidence of DRE was 42%. Risk factors were age onset, prior neurological deficits, and abnormal EEG. CPR can be established and stratified the prediction using scores into 3 levels such as low risk (score<6), moderate risk (score 6-12) and high risk (score>12) with positive likelihood ratio of 0.5, 1.8 and 12.5 respectively. CONCLUSIONS: CPR with scoring risks were stratified into 3 levels. The strongest risk is prior global neurological deficits.

Risk of seizure recurrence following a first unprovoked seizure in children.

The aim of the study was to determine seizure recurrence rate and risk factors of a first unprovoked seizure in children. Ninety-one children aged 2 months-15 years who had a first unprovoked seizure were enrolled and followed-up. History and physical examination were undertaken. The results were displayed as a Kaplan-Meier survival curve. Multivariate analysis was performed with Cox proportional-hazards model. The cumulative probability of recurrence rate was 68 per cent and incidence density was 6.85 per 100 person-months. The cumulative risk of recurrence was 50 per cent at 4 months and 66 per cent at 12 months. No risk of seizure recurrence was found in this study.