Eleanor Flynn

Only the best : medical student selection in Australia

Selection processes for medical schools need to be unbiased, valid, and psychometrically reliable, as well as evidence‐based and transparent to all stakeholders. A range of academic and non‐academic criteria are used for selection, including matriculation scores, aptitude tests and interviews. Research into selection is fraught with methodological difficulties; however, it shows positive benefits for structured selection processes. Pretest coaching and “faking good” are potential limitations of current selection procedures. Developments in medical school selection include the use of personality tests, centralised selection centres and programs to increase participation by socially disadvantaged students.

The medical educator, the discourse analyst, and the phonetician: a collaborative feedback methodology for clinical communication.

Frameworks for clinical communication assist educators in making explicit the principles of good communication and providing feedback to medical trainees. However, existing frameworks rarely take into account the roles of culture and language in communication, which can be important for international medical graduates (IMGs) whose first language is not English. This article describes the collaboration by a medical educator, a discourse analyst, and a phonetician to develop a communication and language feedback methodology to assist IMG trainees at a Victorian hospital in Australia with developing their doctor–patient communication skills. The Communication and Language Feedback (CaLF) methodology incorporates a written tool and video recording of role-plays of doctor–patient interactions in a classroom setting or in an objective structured clinical examination (OSCE) practice session with a simulated patient. IMG trainees receive verbal feedback from their hospital-based medical clinical educator, the simulated patient, and linguists. The CaLF tool was informed by a model of language in context, observation of IMG communication training, and process evaluation by IMG participants during January to August 2009. The authors provided participants with a feedback package containing their practice video (which included verbal feedback) and the completed CaLF tool. The CaLF methodology provides a tool for medical educators and language practitioners to work collaboratively with IMGs to enhance communication and language skills. The ongoing interdisciplinary collaboration also provides much-needed applied research opportunities in intercultural health communication, an area the authors believe cannot be adequately addressed from the perspective of one discipline alone.

The Care of the Very Old in the Last Three Days of Life

BACKGROUND As life expectancy has increased, the age at which people are dying has also increased. There is limited knowledge of the experience of dying of the very old. We sought to examine the last 3 days of life for the very old, dying in a palliative care unit, focusing upon symptom burden and medications prescribed. METHODS A retrospective review of medical records of consecutive patients who died in two inpatient palliative care units. Information collated included demographic and medical information, symptom data, and medications (opioids, benzodiazepines and antipsychotics) administered. Analysis comparing patients aged 80 years and older (cases) and those in the median age range of the treating palliative care units, that is, those aged 50 to 70 years (comparators) were conducted. RESULTS One hundred five cases and 100 comparators were identified. Analysis revealed a significantly shorter length of stay in the cases (13 days) compared to comparators (19 days; p≤0.01).) In the last 3 days, cases received significantly less parenteral morphine equivalents (82.8 versus 170.5 mg, p<0.05), midazolam (12.1 versus 19.1 mg, p<0.05), and lorazepam equivalents (0.9 versus 2.4 mg, p<0.01). Overall, symptom profiles between the groups were similar. IMPLICATIONS The very old appear to have a distinct experience of palliative inpatient care with shorter admissions, and lower requirements for medication. Reasons for lower medication requirements are discussed, and the need for future prospective studies in this area is highlighted. A better understanding of the needs of this population at end of life will enable adequate service planning and improved care.

How we developed Doctors Speak Up: an evidence-based language and communication skills open access resource for International Medical Graduates

Abstract Background: Some International Medical Graduates (IMGs) need to develop language and communication skills for patient-centred care but have limited opportunities to do so. Aim: To develop an evidence-based, language and communication skills web resource for IMG doctors and supervisors, focussing on culturally challenging patient interviews. Methods: Forty-eight IMGs participated in four practice OSCEs. We video-recorded the interactions and applied discourse analytic methods to investigate salient language and communication features. Results: The findings from the OSCE workshops showed that many participants demonstrated aspects of patient-centred interviewing but were hindered by limited interactional competence to elicit information and negotiate behaviours as well as a limited repertoire of English grammar, vocabulary, and phonological phrasing for effective interaction. These findings guided the choice of content and pedagogy for the development of the web-based resource Doctors Speak Up. Conclusion: Evaluation and uptake of the Doctors Speak Up website confirm the demand for a resource combining targeted communication skills and language instruction. Over 19 500 users visited the website between March 2012 and November 2013.

Training for staff who support students

Front‐line administrative, academic and clinical teaching staff often find themselves providing pastoral and learning support to students, but they are often not trained for this role, and this aspect of their work is under‐acknowledged.

Rapid death after admission to palliative care

Background:  Palliative care units provide non‐curative treatment and support to patients with terminal illness. Brief end‐of‐life admissions are disruptive for patients and their families, and increase staff stress. Extremely rapid deaths (survival <24 h from admission) are particularly challenging for all involved. From 1 January 2010 to 23 August 2011, 256 patients died on the Palliative Care Unit (Caritas Christi) at St Vincents Hospital Melbourne. Forty‐two died within 24 h (16%), while 214 survived beyond 24 h (84%).

Medical education of attention : A qualitative study of learning to listen to sound

Abstract Introduction: There has been little qualitative research examining how physical examination skills are learned, particularly the sensory and subjective aspects of learning. The authors set out to study how medical students are taught and learn the skills of listening to sound. Methods: As part of an ethnographic study in Melbourne, 15 semi-structured in-depth interviews were conducted with students and teachers as a way to reflect explicitly on their learning and teaching. Results: From these interviews, we found that learning the skills of listening to lung sounds was frequently difficult for students, with many experiencing awkwardness, uncertainty, pressure, and intimidation. However not everyone found this process difficult. Often those who had studied music reported finding it easier to be attentive to the frequency and rhythm of body sounds and find ways to describe them. Conclusions: By incorporating, distinctively in medical education, theoretical insights into “attentiveness” from anthropology and science and technology studies, the article suggests that musical education provides medical students with skills in sensory awareness. Training the senses is a critical aspect of diagnosis that needs to be better addressed in medical education. Practical approaches for improving students’ education of attention are proposed.

From paperwork to parenting: experiences of professional staff in student support

For academic staff, responding to student concerns is an important responsibility. Professional staff, or non‐academic staff who do administrative work in medical schools, are often the first to be approached by students, yet there is little research on how they manage student issues. Informed by the conceptual framework of emotional labour, we examined the experiences of professional staff, aiming to identify theoretical and practical insights for improving the provision of student support. We examined the scope of support provided, the impact of providing this support on staff and how these impacts can be managed.

Visualizing death and burial: past and present.

The image used to illustrate this editorial comes from a late medieval Book of Hours and shows some of the rituals related to death and burial at the time (Figure 1). For the Christian people of medieval Western Europe death was not only a common occurrence, but also one that was illustrated in many places in their lives. In their churches they would see sculptures of the Last Judgment above the front doors, a Dance of Death inside the back door, and along the walls funerary monuments. Above them were stained glass windows as well as altarpieces that might show the Death of the Virgin or other saints. At home there would be more panel paintings, as well as the illuminations of death-related rituals in the Office of the Dead in their books of hours, and the woodcuts of the Good Death in their Ars Moriendi books. While this death-related art from churches and prayer books of the late medieval and early renaissance periods (much of it now in museums and libraries) is often very beautiful, some is gruesome and was meant to frighten the viewer. Does this mean that medieval men and women were death obsessed? Without going into the detailed historical arguments for and against this proposition (Wieck, 1999; Duffy, 2005), it is obvious from a study of the period that death was something that was likely to impinge on the consciousness of most people on most days. This was either because someone in their kinship group was dying or had recently died or because they were confronted by representations of death. Would a daily reminder of death make those of us who care for old people in postmodern 21st century environments provide better care? Would the thought that death might occur for any of our patients on any day make us communicate more carefully with them and their relatives and friends, as well as consider judiciously the need for investigations and complicated therapies? Also most of the patients looked after by clinicians who work in Psychiatry of Old Age will have experienced the deaths of one or more of their close family members or friends, possibly recently. I suggest that an awareness of how these losses, with their accompanying grief plus their own concerns about death, might affect older people is part of the skill set needed to work in the field. Perhaps a way of considering these issues is to ask if we can normalize death? And if we can, should we? We can define “normalize” as: “to make normal or regular” (OUP, 1973). The educated person (in the street) when asked about normalizing death might suggest those actions and beliefs that can help us to make sense of things that might otherwise overwhelm us. A member of Gen Y might say “making sense of serious stuff.” A Palliative Care colleague suggests that we can only help our patients and their families to normalize death when we understand the cultural, psychological, spiritual, and other elements of the deceased and the bereaved we are involved with, so we can understand the effect of death for those people and its effect on us. For all clinicians, but especially those who look after older people, the concept of normalizing death is the acceptance of the fact that we will all die and the incorporation of this into our clinical practice. The following discussion of death-related images and the meanings to those viewing them at the time of their production may provide some ideas to assist us all in our considerations of death and its meaning to ourselves and our patients. The focus is on illustrations (in the broadest sense) from Christian late medieval Western Europe and 21st century Australia discussing the depicted actions of the dying and the bereaved in their attempts to normalize death for themselves. The principal change in the thinking and actions related to dying and death between these two times is a transition from worrying about the fate of the soul of the dead person to worrying about the fate of the mind of the bereaved person. These changes occurred over a long period of decreasing belief in an afterlife coupled with an increasing emphasis on the primacy of the feelings of the individual in any situation. Concomitant with the decrease in religious belief has been the increase in the belief of the power of medicine in the minds of the general public. As an aside, this belief in the power of medicine by members of the community causes those of us who look after the old and the dying to spend a lot of time preaching the medicine of diminished expectations. One of the commonest types of the medieval images mentioned above is that of death in the midst of life. The three common instances of this of this familiar trope were: the Dance of Death, the three living and the three dead, and death and the maiden (which may be seen as a version of the three living and the three dead). In the latter two instances, this was often depicted as death appearing unexpectedly

A resource for teaching emergency care communication.

Communication in emergency departments (EDs), often between several health professionals and patients and relatives, is a major cause of patient complaint and error; however, communication‐skills teaching for medical students largely focuses on individual clinician–patient interactions.