Philip Cotton

Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: randomised controlled trial

Objective To determine whether supported self management in chronic obstructive pulmonary disease (COPD) can reduce hospital readmissions in the United Kingdom. Design Randomised controlled trial. Setting Community based intervention in the west of Scotland. Participants Patients admitted to hospital with acute exacerbation of COPD. Intervention Participants in the intervention group were trained to detect and treat exacerbations promptly, with ongoing support for 12 months. Main outcome measures The primary outcome was hospital readmissions and deaths due to COPD assessed by record linkage of Scottish Morbidity Records; health related quality of life measures were secondary outcomes. Results 464 patients were randomised, stratified by age, sex, per cent predicted forced expiratory volume in 1 second, recent pulmonary rehabilitation attendance, smoking status, deprivation category of area of residence, and previous COPD admissions. No difference was found in COPD admissions or death (111/232 (48%) v 108/232 (47%); hazard ratio 1.05, 95% confidence interval 0.80 to 1.38). Return of health related quality of life questionnaires was poor (n=265; 57%), so that no useful conclusions could be made from these data. Pre-planned subgroup analysis showed no differential benefit in the primary outcome relating to disease severity or demographic variables. In an exploratory analysis, 42% (75/150) of patients in the intervention group were classified as successful self managers at study exit, from review of appropriateness of use of self management therapy. Predictors of successful self management on stepwise regression were younger age (P=0.012) and living with others (P=0.010). COPD readmissions/deaths were reduced in successful self managers compared with unsuccessful self managers (20/75 (27%) v 51/105 (49%); hazard ratio 0.44, 0.25 to 0.76; P=0.003). Conclusion Supported self management had no effect on time to first readmission or death with COPD. Exploratory subgroup analysis identified a minority of participants who learnt to self manage; this group had a significantly reduced risk of COPD readmission, were younger, and were more likely to be living with others. Trial registration Clinical trials NCT 00706303.

The influence of structural and institutional change on teaching and culture in clinical settings: An exploratory study

Abstract Objectives: Learning in clinical settings is a function of activity, context and culture. Glasgow University’s Medical School has undergone significant curricular change in recent years. This has coincided with change to National Health Service consultants’ contracts, the introduction of the European Working Time Directive and the Modernising Medical Careers training initiative. We wished to explore teachers’ and students’ perspectives on the effects of change on our clinical teachers’ capacity for teaching and on medical culture. Methods: A qualitative approach using individual interviews with educational supervisors and focus groups with senior clinical students was used. Data were analysed using a “framework” technique. Results: Curricular change has led to shorter clinical attachments in the senior clinical rotation, which combined with more centralised teaching have had adverse effects on both formal and informal teaching during attachments. Consultants’ NHS contract changes the implementation of the European Working Time Directive and changes to postgraduate training have adversely affected consultants’ teaching capacity, which has had a detrimental effect on their relationships with students. Medical culture has also changed as a result of these and other societal influences. Conclusions: The apprenticeship model was still felt to be relevant in clinical settings. This has to be balanced against the need for systematic teaching. Structural and institutional change affects learning. Faculty needs to be aware of the socio-historical context of their institutions.

Student-patient communication during physical examination.

Background:  Communication during the physical examination has been understudied. Explicit, evidence‐based guidance is not available as to the most effective content or process of communication while performing physical examination, or indeed how to teach this to medical students. The objective of this exploratory study was to explore how medical students communicate with patients when performing a physical examination in the absence of formal teaching on how to communicate in this situation.

Innovations and developments

We have two items this time. First we hear about something that could arguably be described as heroic. In these straitened times, the Leeds Unit of Primary Care has been running an innovative BSc in primary care. Not a luxury or a folly, surely, but heroic. Our second item comes from Glasgow and is about the CARE Approach for learning about consultations and compassionate care. The Approach is described in some detail and there is a link to the manual. There is much that is novel about this method.

Implementing One Health as an integrated approach to health in Rwanda

It is increasingly clear that resolution of complex global health problems requires interdisciplinary, intersectoral expertise and cooperation from governmental, non-governmental and educational agencies. ‘One Health’ refers to the collaboration of multiple disciplines and sectors working locally, nationally and globally to attain optimal health for people, animals and the environment. One Health offers the opportunity to acknowledge shared interests, set common goals, and drive toward team work to benefit the overall health of a nation. As in most countries, the health of Rwandas people and economy are highly dependent on the health of the environment. Recently, Rwanda has developed a One Health strategic plan to meet its human, animal and environmental health challenges. This approach drives innovations that are important to solve both acute and chronic health problems and offers synergy across systems, resulting in improved communication, evidence-based solutions, development of a new generation of systems-thinkers, improved surveillance, decreased lag time in response, and improved health and economic savings. Several factors have enabled the One Health movement in Rwanda including an elaborate network of community health workers, existing rapid response teams, international academic partnerships willing to look more broadly than at a single disease or population, and relative equity between female and male health professionals. Barriers to implementing this strategy include competition over budget, poor communication, and the need for improved technology. Given the interconnectedness of our global community, it may be time for countries and their neighbours to follow Rwandas lead and consider incorporating One Health principles into their national strategic health plans.

Capacity-building for equitable global health research from Africa: the power of two

The editorial ‘‘Productive global health research from Africa: it takes more’’ (Waiswa 2015) is an important awakening for global health professionals to the challenges for carrying out effective research in Africa. Our experience is from a twinning partnership for capacity-building for global health research through a Ph.D. at the University of Rwanda and Aarhus University in Denmark (Schriver et al. 2015). We adopted a twinning model based in Rwanda linking a Ph.D. student from each country. In our case, practical and administrative challenges raised in the editorial were facilitated through the twinning model. For example, when applying for diploma recognition for the Rwandan twin from the Danish Ministry of Higher Education and Science, a busy supervisor might have given up at first rejection. The interdependency of the linked Ph.D. students gave a strong mutual interest in helping each other navigate the bureaucracy. This is helpful where understanding language, culture and other contextual issues can be essential for progress. Twinning for research entails continuous creative exchange and mutual support, beneficial both in establishing and sharing strategic networks, ensuring safe and effective working conditions and preparing sound, team-based research. Such collaboration may also break the solitude of individual Ph.D. students as well as build the readiness for creating and working in research groups. In obtaining visa, both universities played a crucial role for the Ph.D. twins. We suggest academic institutions engage in constructive dialogues with governments through their consular services to further facilitate timely processing of visa applications. The editorial describes funding of individual candidates as a barrier for raising innovative research capacity. We suggest this barrier rather be due to the organisation around the Ph.D. than the funding model itself. Individually funded Ph.D. students in Africa enrolled at a foreign University and strongly anchored within their local University are more likely to build local research capacity. Developing research infrastructure often begins with individuals in strong local networks. For instance, contribution to local faculty development around research could be amongst the tasks. The Twin Ph.D. model is of relatively low cost whilst yielding synergetic benefits. Close collaboration and flexible funding models further improve the match between local needs and sponsor interests. Nurturing institutional and individual links may improve conditions for subsequent postdoctoral training. It is important to maintain advantages in place for the Ph.D. student, such as office and internet access, and journal access locally and abroad. There is a fine balance when advocating for retention of workload at the home institution and therefore demanding additional tasks of Ph.D. students. Anecdotally, Ph.D. students enrolled in a European university on a project in their home country in Africa progress less effectively whilst at home as when in Europe. Reasons include competing tasks back home—teaching, meetings and other academic and research tasks often in less optimal environment, distracted by inescapable social and family (and extended African family) pressures. In a related article by V. K. Cubaka M. Schriver P. Kallestrup Department of Public Health, Center for global health, Aarhus University, Aarhus, Denmark

How junior doctors internalise, process and manage errors

Young doctors strive to perform to the highest level, and in pursuit of perfection errors inevitably occur. How junior doctors internalise, process and manage errors is the subject of this paper. Coping mechanisms are infl uenced by two universal emotional responses: guilt and shame. By and large, shame causes withdrawal and guilt causes a series of conciliatory responses. The authors start with the psychology literature, and move to consider shame and guilt in the medical education literature, and specifi cally the relationship between shame and coping strategies, reduced empathy and diffi culties with forgiving oneself.

Worldly wise: The challenges for global professionals

In this themed issue, examining medical professionalism, the authors take five perspectives on health care education in an era of globalisation. Much of the content of the concerns expressed depend on where you are when reading these papers and all of them warrant global south perspectives. Tan & McNeill (2015) write of ‘widespread threats to professionalism’ in an age of globalisation. They highlight some of the challenges which doctors, their employers and the public face from the movement and migration of professionals. The gains of globalisation are presented as temptations for the weak and rich pickings for opportunists. There is, of course, a difference between doctors acting criminally and systems that permit doctors to earn amounts in a way beyond reason. As long as people will pay high prices in the belief that they get better and more effective care, there will be doctors to deliver the care and get remunerated for providing it. For some time, we have accepted that some choose to believe that the more painful the administration of a drug the more potent its action, and paying more may be just another form of placebo effect. It is morally unjust to prevent a doctor from trying to make a better life for themselves and their family when remuneration is poor. However, preying on the vulnerable, using swish marketing to mislead, and profiting from the sale of procedures that have no evidence base, are harms. The training of medical doctors like the rest of higher education is a commodity. The value is determined by the market and by the buyer. There are many examples of income streams for universities that come from selling medical education to high bidders. These efforts are not tainted by the scale of financial transaction but by the fact that we do not see universities matching these lucrative activities in resourcepoor environments. However, we have a positive story to tell in Rwanda where a pledge by some of the top US universities to reduce their own costs has facilitated the delivery of highquality and much more affordable education. There can be few other examples of such a comprehensive contribution to nursing and medical education. All these actions tell about the values that are driving the institutions. In many parts of the world, medical schools are cash cows for their universities and the imperatives to sell the product comes from the universities that own the schools, and by the international ratings that reward such activities. There may be an element of personal ambition or vanity, or financial profit for those who broker these deals, but who can tell? At the end of the day, these schools can legitimately claim to be advancing care through training – and if they don’t do it, a competitor will. The papers in this issue of the Journal focus on medical education and this must only ever be part of the story of the future of health care teaching and training. The world needs highly trained nurses and midwives and much more; it needs to value them as highly as doctors. Every aspect of each of these papers should apply to nurse education and employment – access to digital media for teaching and training, and in the work place, sensitivity to professional transitions as staffs migrate, and characteristics of behaviours in challenging situations. In addition, medical tourist destinations are nothing without security, good facilities, and trained, experienced and expert nursing and support staff, and many may be operated by clinicians turned entrepreneurs, who should not turn their backs on professional obligations and codes of practice. The active lobbying of groups such as Primafamed (2015) are welcome as they keep discussions going about rich nations paying poorer nations for the training costs of the staff they import. It is easy to cast big pharma as the enemy but the fact is that they are businesses accountable to shareholders and with little evidence that questionable and repugnant practices in research and pricing have changed. They are not the global health baddies because of globalisation. With trust, we can hope. McKimm’s & Wilkinson’s (2015) paper harks to the literature on retention in higher education and the key message to emerge which is about a sense of belonging; of creating community. There is shared experience of the student from the global north who behaves in a manner that would be inappropriate in his or her own system while on placement in the south, and heaps self-justification by describing local needs, and the opportunity s/he had to gain experience. There is no difference between electives and training or working, and the potential for harm is possibly greater. Respective roles and the supervision and control of them have to be very different, and our collective responsibility is to brief students

The next generation of Rwandan physicians with a primary health care mindset

Globally there is a need for well-trained primary health care physicians at the district level. Physicians who focus on ambulatory care will be in greater demand in addressing the global burden of chronic disease and multi-morbidity, which are on the increase in Africa. Not surprisingly, family medicine has grown stronger on the African continent in the past decades. In Rwanda, education of health professionals has recently undergone several changes. Postgraduate training in medical and surgical specialties has been further developed in a constructive and inclusive way with support of American universities. Although postgraduate training in family and community medicine has been temporarily halted, the need to develop and enhance undergraduate training in social and community medicine was identified and efforts have since commenced. This raises the question whether postgraduate training was developed too early, at a time when undergraduate training did not yet embrace the concept of primary health care.

Can medical students' pre-curriculum performance on the Ethics in Health Care Instrument (EHCI) be used as a predictor of future academic performance? A pilot study.

There is a body of research showing how deliberate practice (defined as ‘‘a regimen of effortful activities designed to optimize improvement’’) relates to the acquisition and maintenance of expert performance in various domains of expertise including medicine (Ericsson 1993). There is little information in the literature about the practice habits of medical students for learning clinical examination skills. A study by Mavis (2000) showed that for students who practised for more than three hours before an objective structured clinical examination (OSCE), only 20% of their time was spent practising clinical skills. Our aim was to identify the clinical skills practice habits of medical students outside of their timetabled clinical skills sessions; understand what factors influence these practice behaviours; and explore how practice opportunities could be improved. An anonymous, self-completed survey tool was designed and distributed to all second and third year undergraduate medical students at the University of Auckland at the end of 2004. Data were coded and analysed using univariate statistics. The response from Year 3 was moderate (79/1181⁄4 67%) with a lower rate from Year 2 (67/1411⁄4 48%). Year 2 students were more likely to have never practised examination skills outside of timetabled clinical skills sessions as compared with year 3 students (28.8% versus 5.1%). Most year 3 students (46/531⁄4 86.8%) specifically practised before the end-of-year clinical exam. Year 3 students were more likely to use the skills centre compared with year 2 students who tended to practise at home. Students practised complex skills (blood pressure, neurology) more often. Analysis of open questions on how opportunities for practice could be improved identified two main themes: (i) access to skills centre and (ii) supervision. In conclusion, formal clinical assessment has an influence on the how, when, and what students practice. A dedicated clinical skills centre provides a suitable location for practice that students use in proportion to their exposure and familiarity with the resource. Increasing access to the centre would improve the number and type of opportunities to practise clinical skills. We hope to further explore the opportunities for senior peer supervision and study the transition from early skills learning to learning in the health service environment.