Michele Daly

A longitudinal integrated placement and medical students' intentions to practise rurally.

Medical Education 2012: 46 : 179–191

What factors in rural and remote extended clinical placements may contribute to preparedness for practice from the perspective of students and clinicians

Background: Community-based rural education opportunities have expanded in Australia, attracting more medical students to placements in rural and remote settings. Aim: To identify the factors in an integrated, community-engaged rural placement that may contribute to preparedness for practice (P4P) from the perspective of students and clinicians. Method: Forty-two semi-structured interviews with medical students, supervisors and clinicians analysed thematically. Results: Opportunities for clinical learning, personal and professional development and cultural awareness were reported by students and clinicians as key factors that contribute to P4P. Potential barriers in rural and remote settings included geographical and academic isolation, perceived educational risk and differing degrees of program engagement. Conclusions: A longitudinal clinical placement in a rural setting may enable development of enhanced competencies leading to P4P. A rural setting can provide a unique experience through hands-on learning, enhanced personal and professional development opportunities and observation of the cultural and contextual impact on health.

Longitudinal integrated rural placements: a social learning systems perspective

Objectives  There is currently little theoretically informed exploration of how non‐traditional clinical placement programmes that are longitudinal, immersive, based on community‐engaged education principles and located in rural and remote settings may contribute to medical student learning. This paper aims to theoretically illustrate the pedagogical and socio‐cultural underpinnings of student learning within a longitudinal, integrated, community‐engaged rural placement.

The emotional well-being of young people having a parent with younger onset dementia

Younger onset dementia (YOD) not only affects the person with the diagnosis but the whole family, which often includes young people. A limited body of research on this group of young people indicates that they experience varying degrees of emotional trauma. We explored the lived experiences of young people having a parent with YOD from the perspective of the social model of disability. Data were available from semi-structured interviews with 12 young people who had a parent with YOD looking at their lived experiences between 8 and 24 years. Thematic analysis identified four main themes: the emotional toll of caring, keeping the family together, grief and loss and psychological distress. The social model of disability theory provides a helpful framework for these families who experience significant emotional distress, demonstrating that the disability is often socially constructed by a society, which marginalizes and excludes them. A ‘whole family’ approach is proposed, where the needs of young people and their parents are respected and responded to age appropriately.

Psychological morbidity in Australian doctors who have and have not experienced a medico-legal matter: cross-sectional survey.

Objective: To describe the differences in psychological morbidity between Australian general practitioners (GPs) who have experienced a medico-legal matter and those who have not. Methods: A total of 1499 GPs were initially invited to participate in the study. Two hundred and sixty requested not to participate, with 1239 subsequently being sent a survey. There were 566 respondents (45.7% response rate to survey). There were two sources of data. First, a cross-sectional survey sought demographic information, personality traits via the Eysenck Personality Questionnaire (EPQ), history of a medico-legal matter with any medical defence organization, and measures of psychological morbidity, including the General Health Questionnaire (GHQ), Sheehan Disability Scale (SDS), and Alcohol Use Disorders Identification Test. Second, information was extracted from the United Medical Protection database on medico-legal matters. Results: Fifty-nine per cent of respondents to the survey reported ever having a medico-legal matter, with 13% having a current medico-legal matter. Those with a current matter reported increased levels of disability (in work, social or family life) and higher prevalence of psychiatric morbidity (45% vs 27% GHQ ‘case identification’ rates), compared to those with no current matter. Those respondents with a history of past medico-legal matters reported increased levels of disability (SDS) and depression subscores (GHQ). Male respondents drank significantly more alcohol than female respondents, and male respondents with current or past medico-legal matters had significantly higher levels of alcohol use than male respondents with no experience of medico-legal matters. Conclusions: Doctors who have current and past medico-legal matters have a higher level of psychological morbidity. The study design was unable to distinguish cause or effect. A longitudinal study is planned to investigate this. The findings have significant implications for medical training, doctor support systems and medical insurance groups.

Personality, gender and medico-legal matters in medical practice

Objectives: The aim of this paper was to explore the relationship between the personality traits of Australian General Practitioners (GPs) and their gender, work practice arrangements, and history of medico-legal matters. Methods: A cross-sectional self report survey was mailed to 1239 GPs. There were 566 respondents (45.7% response rate to survey). The survey assessed personality traits (using the Eysenck Personality Questionnaire), demographic and practice information, and history of medico-legal matters with any medical defence organization. The number and type of medico-legal matters was also extracted from the UNITED Medical Protection database. Results: Male respondents had significantly higher psychoticism scores than females (p<0.001), and females had significantly higher neuroticism scores than males (p<0.01), as in community samples. However, for GPs who worked more than 48 hours per week, there were no gender differences in personality trait scores. Solo practitioners and non-solo practitioners did not differ on personality scores. Proceduralists and non-proceduralists did not differ on personality scores. However, a higher proportion of proceduralists experienced a medico-legal matter than non-proceduralists (p<0.001). There was a positive correlation between extraversion scores and doctors who attended peer review (p<0.001). There was no difference in the numbers of medico-legal matters for doctors who attended peer review. Males who self reported a medico-legal matter had higher neuroticism scores than the males who did not report medico-legal matters. This was not the case for females. For males, this pattern was not replicated when considering data from UNITED. Conclusions: The known demographic and practice factors that differ for doctors having a medico-legal matter are replicated here – being male, a proceduralist and working longer hours. There is not a consistent pattern regarding personality traits and medico-legal matters.

Empowerment of young people who have a parent living with dementia: a social model perspective

BACKGROUND Socially constructed disablement has marginalized young people in families where a parent has younger onset dementia (YOD). This has contributed to inadequate societal support for their complex situation. Impacts on such young people include significant involvement with mental health services for themselves. In this paper, we explored the young peoples lived experiences in these families and the influencing factors to enable these young people to be included and supported within their community. METHODS In this qualitative research study, the social model of disability was used as the theoretical framework in conducting a thematic analysis of interviews with 12 participants. RESULTS Three themes emerged; invisibility highlighting the issues of marginalization; connectivity foregrounding the engagement of young people with family, friends and their social networks, and being empowered through claiming their basic human right to receive the age appropriate support they needed. CONCLUSION The current plight of young people living with a parent with YOD demands a fundamental shift by society in developing inclusive cross-sectorial cooperation linking service providers across youth and dementia sectors. This requires working in partnership with the service users responding to the identified needs of individual family members.

Identity, impairment and disablement: exploring the social processes impacting identity change in adults living with acquired neurological impairments

Abstract The social model of disability acknowledges the impact of impairments but argues that disablement is socially constructed. Taking a theoretical perspective, underpinned by the social model of disability and elements of social identity theory, we investigated the relationship between impairment, disablement and identity change in adults living with an acquired neurological impairment. Through the thematic analysis, three themes emerged: changing self described the personal factors for identity change in people acquiring impairment; changing communities explored the contextual factors creating both socially constructed disablement and identity change; and influencing identity change considered strategies adopted by individuals to both counter socially constructed disablement and promote exploration of identity. A systemic change towards acknowledgement and valuing a disabled identity may counter socially constructed disablement and support enablement and social inclusivity.

The multiple spaces for health professional students' learning.

Editor – Ross and Pillay’s recent account of the higher education experiences of rural health care professionals illustrates how alternative learning spaces (including informal and social spaces) provide valuable opportunities for ‘collaboration and for the reconfiguring of the participants’ agency to be, think and act differently’. Resonating with the notion of learning as a social process, their paper also reinforces the implication that student learning is supported by relationships with significant others such as peers, tutors and other health care professionals. We support these findings, but suggest there is one critical issue worthy of consideration. In our research on medical student learning within rural and remote longitudinal clinical placements (also known as longitudinal integrated clerkships [LICs]), we used the theoretical lens of social learning systems to illustrate how student learning occurred within distinct yet interrelated spaces characterised by varying degrees of formality, membership and interaction, and different learning opportunities. Connectivity, a key element, explained how students crossed boundaries between these learning spaces and embedded communities, and in doing so, developed a more complex sense of professional self.

Preparing for practice with longitudinal integrated placements.

As fourth year medical students from Cardiff University Surgical Society (CUSS) we discussed your article (Daly et al. 2013) with interest. We acknowledge that our experiences in this field differ from those in Australia. However, regarding medical education in the UK, placements allocated by Cardiff University are geographically vast and remote. These include exposure to rural South Wales and North Wales where Welsh language is predominantly spoken. Therefore, we feel uniquely positioned to comment on experiences of rural placements because such 5–8 week attachments are integrated into our core-curriculum. CUSS agrees with Daly et al. that rural placements may enhance preparedness for practice (P4P) specifically in reference to clinical skills, personal, professional and cultural development. Factors contributing to our increased P4P differ from those at Broken Hill. Anecdotally we have identified these as: increased devoted clinician teaching time, lower student-patient ratio, and a more culturally, pathologically and socially diverse spectrum of patients. Within CUSS we discussed various negative aspects of rural placements absent from the original article. We believe student experience is a key criterion in determining perceived placement success, which in turn may affect the knowledge and P4P acquired during attachments. Firstly, logistical obstacles specifically affecting Cardiff students include language barriers, unsubsidized travel costs and social isolation from peers. Additionally, in Cardiff, we rotate through specialty specific placement blocks each situated at discrete locations. This means rurally placed students will lack exposure to specialist teaching, patients requiring complex management and advanced procedures only offered at tertiary centres. Daly et al. mentioned using Video-conferencing to overcome these issues. This method is currently employed by Cardiff University. However, based on our experience this format is a poor substitute when compared to face-to-face interactions. We conclude that students should experience a balance between rural and tertiary care settings. While rural placements can potentially increase P4P, the aforementioned detrimental features should be considered as these may negatively affect student satisfaction, learning opportunities and therefore reflect poorly on P4P. Furthermore, we call for an objective measure of P4P to determine whether students’ perceptions are reflected in subsequent clinical practice.