Jianzhen Zhang

The "Pyramid of Professionalism": Seven Years of Experience With an Integrated Program of Teaching, Developing, and Assessing Professionalism Among Medical Students

The authors report on an integrated program of teaching, developing, and assessing professionalism as well as managing unprofessional behavior referrals and supporting students through the Personal and Professional Development Committee (PPDC) in the four-year, graduate-entry medical program at the School of Medicine, University of Queensland, Australia. Two thousand six hundred thirty medical students have participated in the ethics and professional practice teaching program from 2000 to 2006. They were assessed through formal examination; students who did not satisfy requirements completed supplementary examinations. One student failed a year on the basis of formal examination. Instructors referred 507 students (19% of all enrolled) during the seven-year period to the PPDC, which interviewed 142 (25%; 5% of all enrolled) at least once; 25 of these more than once. In all, 711 reports were submitted to the PPDC, 420 (55%) for unsatisfactory attendance only and 291 (45%) for other concerns. Most of these related to responsibility/reliability (46.7%) and participation (41.9%);12.4% related to honesty/integrity [corrected] The PPDC referred four students to the board of examiners, and two students failed a year for persistent unprofessional behavior. The authors established a Pyramid of Professionalism whose foundation is a formal curriculum of medical ethics, law, and professionalism. At higher levels, the pyramid mirrors Australias medical regulatory processes, combining nonpunitive support with the possibility of sanctions, by mediating and sometimes remediating a range of notified concerns. Students who persist in behaving unprofessionally or in seriously unacceptable ways have failed academically on professionalism grounds.

Systematic review of integrated models of health care delivered at the primary-secondary interface: how effective is it and what determines effectiveness?

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary-secondary care. Six elements were identified that were common to these models of integrated primary-secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary-secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.

Student approaches for learning in medicine: what does it tell us about the informal curriculum?

BackgroundIt has long been acknowledged that medical students frequently focus their learning on that which will enable them to pass examinations, and that they use a range of study approaches and resources in preparing for their examinations. A recent qualitative study identified that in addition to the formal curriculum, students are using a range of resources and study strategies which could be attributed to the informal curriculum. What is not clearly established is the extent to which these informal learning resources and strategies are utilized by medical students. The aim of this study was to establish the extent to which students in a graduate-entry medical program use various learning approaches to assist their learning and preparation for examinations, apart from those resources offered as part of the formal curriculum.MethodsA validated survey instrument was administered to 522 medical students. Factor analysis and internal consistence, descriptive analysis and comparisons with demographic variables were completed. The factor analysis identified eight scales with acceptable levels of internal consistency with an alpha coefficient between 0.72 and 0.96.ResultsNearly 80% of the students reported that they were overwhelmed by the amount of work that was perceived necessary to complete the formal curriculum, with 74.3% believing that the informal learning approaches helped them pass the examinations. 61.3% believed that they prepared them to be good doctors. A variety of informal learning activities utilized by students included using past student notes (85.8%) and PBL tutor guides (62.7%), and being part of self-organised study groups (62.6%), and peer-led tutorials (60.2%). Almost all students accessed the formal school resources for at least 10% of their study time. Students in the first year of the program were more likely to rely on the formal curriculum resources compared to those of Year 2 (p = 0.008).ConclusionsCurriculum planners should examine the level of use of informal learning activities in their schools, and investigate whether this is to enhance student progress, a result of perceived weakness in the delivery and effectiveness of formal resources, or to overcome anxiety about the volume of work expected by medical programs.

Case conferences between general practitioners and specialist teams to plan end of life care of people with end stage heart failure and lung disease: an exploratory pilot study

BackgroundMost people die of non-malignant disease, but most patients of specialist palliative care services have cancer. Adequate end of life care for people with non-malignant disease requires acknowledgement of their limited prognosis and appropriate care planning. Case conferences between specialist palliative care services and GPs improve outcomes in cancer-based populations. We report a pilot study of case conferences between the patient’s GP and specialist staff to facilitate care planning for people with end stage heart failure or non-malignant lung disease in a regional health service in Queensland Australia.MethodsSingle face to face case conferences about patients with a primary diagnosis of advanced heart failure or respiratory failure from non-malignant disease were conducted between a palliative care consultant, a case management nurse and the patient’s GP. Annualised rates of service utilisation (emergency department [ED] presentations, ED discharges back to home, hospital admissions, and admission length of stay) before and after case conference were calculated. Content and counts of case conference recommendations, and the rate of adherence to recommendations were also assessed. A process evaluation of case conferences was undertaken.ResultsTwenty-three case conferences involving 21 GPs were conducted between November 2011 and November 2012. One GP refused to participate. Ten patients died, three at home. Of 82 management recommendations made, 55 (67%) were enacted. ED admissions fell from 13.9 per annum (pa) to 2.1 (difference 11.8, 95% CI 2.2-21.3, p = 0.001); ED admissions leading to discharge home from 3.9 to 0.4 pa (difference 3.5, 95% CI -0.4-7.5, p = 0.05); hospital admissions from 11.4 to 3.5 pa (difference 7.9, 95% CI 2.2-13.7, p = 0.002); and length of stay from 7.0 to 3.7 days (difference 3.4, 95% CI 0.9-5.8, p = 0.007). Participating health professionals were enthusiastic about the process.ConclusionsThis pilot is the initial step in the development and testing of a complex intervention based on a model of integrated care. A single case conference involving the patient’s heart or lung failure team is associated with significant reductions in service utilization, apparently by improving case coordination, enhancing symptom management and assessing and managing carer needs. A randomized controlled trial is being developed.Trial registrationAustralian and New Zealand Controlled Trials Register ACTRN12613001377729: Registered 16/12/2013.

Impact of an integrated model of care on potentially preventable hospitalizations for people with Type 2 diabetes mellitus.

To evaluate the impact of an integrated model of care for patients with complex Type 2 diabetes mellitus on potentially preventable hospitalizations.

A new model of integrated primary-secondary care for complex diabetes in the community: study protocol for a randomised controlled trial.

BackgroundA new model of complex diabetes care is provided by a multidisciplinary team which incorporates general practitioner (GP) Clinical Fellows supported by an Endocrinologist and diabetes educator within a community-based general practice setting. This study evaluates the health and clinical benefits of the new model of care, assesses the acceptability of the model to patients, GPs and other health professionals, and examines the cost-effectiveness of the model.Methods/DesignThe study is an open, non-inferiority randomised controlled trial with data collected at baseline, 6 and 12xa0months. Participants are identified from new patients on hospital-based diabetes outpatient clinic waiting lists and new GP referrals. Eligible consenting patients are randomised to either a community practice site (intervention) or a hospital site (usual care). In the intervention model, medical care is led by a GP Clinical Fellow in partnership with an Endocrinologist. Quantitative measures include clinical indicators with HbA1c as the primary outcome; patient-reported outcomes include health-related quality of life, mental health and satisfaction with care. Qualitative methods will be used to explore the perspectives and experiences of patients and providers regarding the new model of care. An economic evaluation will also be undertaken.DiscussionThis model of care seeks to improve the quality and safety of healthcare at the interface between the hospital and primary care sectors for patients with complex diabetes. The study will provide empirical evidence about the impact of the model of care on health outcomes, patient and clinician satisfaction, as well as any economic impacts.Trial registrationClinical Trials Registry Number:ACTRN12612000380897

Case conference primary-secondary care planning at end of life can reduce the cost of hospitalisations

BackgroundTo plan integrated care at end of life for people with either heart failure or lung disease, we used a case conference between the patient’s general practitioner (GP), specialist services and a palliative care consultant physician. This intervention significantly reduced hospitalisations and emergency department visits. This paper reports estimates of potential savings of reduced hospitalisation through end of life case conferences in a pilot study.MethodsWe used Australian Refined Diagnosis Related Group codes to obtain data on hospitalisations and costs. The Australian health system is a federation: the national government is responsible for funding community based care, while state and territory governments fund public hospitals. There were 35 case conferences for patients with end stage heart failure or lung disease, who were patients of the public hospital system, involving 30 GPs in a regional health district.ResultsThe annualised total cost per patient was AUD

The work of local healthcare innovation: a qualitative study of GP-led integrated diabetes care in primary health care

90,060 before CC and AUD

Self-sufficiency in intern supply: The impact of expanded medical schools, medical places and rural clinical schools in Queensland

11,841 after CC. The mean per person cost saving was AUD

A qualitative follow-up study of diabetes patients’ appraisal of an integrated diabetes service in primary care

41,023 (