Geoff McColl

It was serendipity: A qualitative study of academic careers in medical education

Despite a demand for educational expertise in medical universities, little is known of the roles of medical educators and the sustainability of academic careers in medical education. We examined the experiences and career paths of medical educators from diverse professional backgrounds seeking to establish, maintain and strengthen their careers in medical schools.

Prolonged prodrome, systemic vasculitis, and deafness in Cogan's syndrome

Cogans syndrome is a rare, multisystem disease which occurs predominantly in children and young adults. It was originally described as the combination of interstitial keratitis and audiovestibular disturbance, but other forms of ocular disease, as well as systemic vasculitis, have since been recognised as part of the syndrome. Diagnosis can be difficult if the various manifestations occur separately, but early recognition is important because prompt treatment may prevent deafness. Two cases are presented here illustrating the features of this disease, and providing histological evidence of systemic vasculitis in both.

Analysing clinical reasoning characteristics using a combined methods approach

BackgroundDespite a major research focus on clinical reasoning over the last several decades, a method of evaluating the clinical reasoning process that is both objective and comprehensive is yet to be developed.The aim of this study was to test whether a dual approach, using two measures of clinical reasoning, the Clinical Reasoning Problem (CRP) and the Script Concordance Test (SCT), provides a valid, reliable and targeted analysis of clinical reasoning characteristics to facilitate the development of diagnostic thinking in medical students.MethodsThree groups of participants, general practitioners, and third and fourth (final) year medical students completed 20 on-line clinical scenarios -10 in CRP and 10 in SCT format. Scores for each format were analysed for reliability, correlation between the two formats and differences between subject-groups.ResultsCronbach’s alpha coefficient ranged from 0.36 for SCT 1 to 0.61 for CRP 2, Statistically significant correlations were found between the mean f-score of the CRP 2 and total SCT 2 score (0.69); and between the mean f-score for all CRPs and all mean SCT scores (0.57 and 0.47 respectively). The pass/fail rates of the SCT and CRP f-score are in keeping with the findings from the correlation analysis (i.e. 31% of students (11/35) passed both, 26% failed both, and 43% (15/35) of students passed one but not the other test), and suggest that the two formats measure overlapping but not identical characteristics. One-way ANOVA showed consistent differences in scores between levels of expertise with these differences being significant or approaching significance for the CRPs.ConclusionSCTs and CRPs are overlapping and complementary measures of clinical reasoning. Whilst SCTs are more efficient to administer, the use of both measures provides a more comprehensive appraisal of clinical skills than either single measure alone, and as such could potentially facilitate the customised teaching of clinical reasoning for individuals. The modest reliability of SCTs and CRPs in this study suggests the need for an increased number of items for testing. Further work is needed to determine the suitability of a combined approach for assessment purposes.

Medical teachers conceptualize a distinctive form of clinical knowledge

For over four decades, there have been efforts to specify the types of knowledge that medical students need, how that knowledge is acquired and how its constituent parts are related. It is one of the areas of continuing concern underlying medical education reform. Despite their importance to medical students’ learning and development, the perspectives of medical teachers in hospitals are not always considered in such discourse. This study sought to generate an understanding of these teachers’ values, perspectives and approaches by listening to them and seeing them in their everyday teaching work, finding and understanding the meanings they bring to the work of medical teaching in hospitals. In interviews, all of the teachers talked more about the optimal forms of knowledge that are important for students than they talked about the form of the teaching itself. Many revealed to students what knowledge they do and do not value. They had a particular way of thinking about clinical knowledge as existing in the people and the places in which the teaching and the clinical practice happen, and represented this as ‘real’ knowledge. By implication, there is other knowledge in medical education or in students’ heads that is not real and needs to be transformed. Their values, practices and passions add texture and vitality to existing ways of thinking about the characteristics of clinical knowledge, how it is depicted in the discourse and the curriculum and how it is more dynamically related to other knowledge than is suggested in traditional conceptualizations of knowledge relationships.

Revisiting the hypothesis-driven interview in a contemporary context

Objective: The “hypothesis-driven interview” was articulated by George Engel as a method of raising and testing hypotheses in the process of building a biopsychosocial formulation and determining the most likely diagnosis. This interview was a forerunner of the modern medical interview as well as the contemporary psychiatric assessment. The objective of this article is to describe the hypothesis-driven interview and to explore its relationship with the contemporary medical interview. Method: The literature on the medical and hypothesis-driven interview was reviewed. Key features of each were identified. Results: The hypothesis-driven interview shares much with the contemporary medical interview. In addition, it enhances the application of communication skills and allows the interviewer to develop a formulation during the course of the assessment. Conclusion: The hypothesis-driven interview is well suited to the aims of a contemporary psychiatric assessment.

Use of monoclonal antibodies to detect disease associated HLA-DRB1 alleles and the shared epitope in rheumatoid arthritis

OBJECTIVE To use a panel of monoclonal antibodies (Mab) which recognise HLA class II alleles associated with rheumatoid arthritis for fluorescence activated cell sorter (FACS) analysis of peripheral blood mononuclear cells (PBMNC) from patients with early and established rheumatoid arthritis and to compare these results against DNA oligotyping of HLA class II molecules in the same patients. METHODS 27 patients (18 from an early arthritis clinic, nine with established rheumatoid arthritis) were studied using both techniques. PBMNC were stained with Mab which recognise the shared epitope, the HLA-DRB1*04 molecule and its *0401, *0404 subtypes in the presence of bound peptide. Mab stained cells were analysed by FACS. Genomic DNA was prepared from PBMNC and used for DNA oligotyping and sequencing by standard methods. RESULTS FACS analysis of Mab stained PBMNC gave identical results to those obtained by DNA oligotyping in 26/27 patients. The antibodies identified the shared epitope in 14/14 cases and the presence of an HLA-DRB1*04 molecule in 12/12 cases. HLA-DRB1*0404 was identified in 4/4 cases. HLA-DRB1*0401 was identified in 5/6 cases. One patient oligotyped as HLA-DRB1*0401, but consistently failed to react with the *0401 Mab. DNA sequencing of the second exon of the HLA-DRB1*0401 allele in this patient confirmed a normal HLA-DRB1*0401 genotype. CONCLUSIONS FACS analysis of PBMNC stained with Mab recognising the shared epitope and rheumatoid arthritis associated HLA susceptibility molecules provides a rapid, reliable, and more accessible alternative to DNA oligotyping. The apparent discordance between phenotypic and genetic analysis of HLA-DRB1*0401 in one patient, may reflect variability in HLA-DRB1*0401 gene expression or in class II peptide presentation.

How clinical reasoning is taught and learned: Cultural perspectives from the University of Melbourne and Universitas Indonesia.

BackgroundThe majority of schools in the Asia-Pacific region have adopted medical curricula based on western pedagogy. However to date there has been minimal exploration of the influence of the culture of learning on the teaching and learning process. This paper explores this issue in relation to clinical reasoning.MethodA comparative case study was conducted in 2 medical schools in Australia (University of Melbourne) and Asia (Universitas Indonesia). It involved assessment of medical students’ attitudes to clinical reasoning through administration of the Diagnostic Thinking Inventory (DTI), followed by qualitative interviews which explored related cultural issues. A total of 11 student focus group discussions (45 students) and 24 individual medical teacher interviews were conducted, followed by thematic analysis.ResultsStudents from Universitas Indonesia were found to score lower on the Flexibility in Thinking subscale of the DTI. Qualitative data analysis based on Hofstede’s theoretical constructs concerning the culture of learning also highlighted clear differences in relation to attitudes to authority and uncertainty avoidance, with potential impacts on attitudes to teaching and learning of clinical reasoning in undergraduate medical education.ConclusionsDifferent attitudes to teaching and learning clinical reasoning reflecting western and Asian cultures of learning were identified in this study. The potential impact of cultural differences should be understood when planning how clinical reasoning can be best taught and learned in the changing global contexts of medical education, especially when the western medical education approach is implemented in Asian contexts.

Where is student support most needed

Barrett and McColl raise the question posed in the title of their commentary to highlight the value of attending to interactions between students and their learning environment.

Expensive medicines: ensuring objective appraisal and equitable access

In response to requests for the funding of new drugs, reimbursement agencies are re-evaluating some of the methods used in assessing these products. Many trials submitted for the regulatory review of new drugs do not provide adequate data for subsidy decisions. We argue that all involved in bringing medicines to market need to be explicit about the additional information required, decide how these data should be collected and assessed and the methods that should be used to set a fair price for a new drug. In Australia, a formal appraisal of the cost–effectiveness and budget impact of a new medicine precedes any subsidy decision at national level. 1 If a new product is subsidized, the government pays an agreed price to the manufacturer, sometimes with requirements for financial contracts to manage expenditure. 2

An Economic Evaluation of Stopping Versus Continuing Tumor Necrosis Factor Inhibitor Treatment in Rheumatoid Arthritis Patients With Disease Remission or Low Disease Activity: Results From a Pragmatic Open-Label Trial

To evaluate, from a societal perspective, the incremental cost‐effectiveness of withdrawing tumor necrosis factor inhibitor (TNFi) treatment compared to continuation of these drugs within a 1‐year, randomized trial among rheumatoid arthritis patients with longstanding, stable disease activity or remission.