S. Ryan Greysen

Medical schools in sub-Saharan Africa.

Small numbers of graduates from few medical schools, and emigration of graduates to other countries, contribute to low physician presence in sub-Saharan Africa. The Sub-Saharan African Medical School Study examined the challenges, innovations, and emerging trends in medical education in the region. We identified 168 medical schools; of the 146 surveyed, 105 (72%) responded. Findings from the study showed that countries are prioritising medical education scale-up as part of health-system strengthening, and we identified many innovations in premedical preparation, team-based education, and creative use of scarce research support. The study also drew attention to ubiquitous faculty shortages in basic and clinical sciences, weak physical infrastructure, and little use of external accreditation. Patterns recorded include the growth of private medical schools, community-based education, and international partnerships, and the benefit of research for faculty development. Ten recommendations provide guidance for efforts to strengthen medical education in sub-Saharan Africa.

Online Professionalism and the Mirror of Social Media

The rise of social media—content created by Internet users and hosted by popular sites such as Facebook, Twitter, YouTube, and Wikipedia, and blogs—has brought several new hazards for medical professionalism. First, many physicians may find applying principles for medical professionalism to the online environment challenging in certain contexts. Second, physicians may not consider the potential impact of their online content on their patients and the public. Third, a momentary lapse in judgment by an individual physician to create unprofessional content online can reflect poorly on the entire profession. To overcome these challenges, we encourage individual physicians to realize that as they “tread” through the World Wide Web, they leave behind a “footprint” that may have unintended negative consequences for them and for the profession at large. We also recommend that institutions take a proactive approach to engage users of social media in setting consensus-based standards for “online professionalism.” Finally, given that professionalism encompasses more than the avoidance of negative behaviors, we conclude with examples of more positive applications for this technology. Much like a mirror, social media can reflect the best and worst aspects of the content placed before it for all to see.

A history of medical student debt: observations and implications for the future of medical education.

Over the last 50 years, medical student debt has become a problem of national importance, and obtaining medical education in the United States has become a loan-dependent, individual investment. Although this phenomenon must be understood in the general context of U.S. higher education as well as economic and social trends in late-20th-century America, the historical problem of medical student debt requires specific attention for several reasons. First, current mechanisms for students educational financing may not withstand debt levels above a certain ceiling which is rapidly approaching. Second, there are no standards for costs of medical school attendance, and these can vary dramatically between different schools even within a single city. Third, there is no consensus on the true cost of educating a medical student, which limits accountability to students and society for these costs. Fourth, policy efforts to improve physician workforce diversity and mitigate shortages in the primary care workforce are inhibited by rising levels of medical student indebtedness. Fortunately, the current effort to expand the U.S. physician workforce presents a unique opportunity to confront the unsustainable growth of medical student debt and explore new approaches to the financing of medical students education.

A survey of Sub-Saharan African medical schools

BackgroundSub-Saharan Africa suffers a disproportionate share of the worlds burden of disease while having some of the worlds greatest health care workforce shortages. Doctors are an important component of any high functioning health care system. However, efforts to strengthen the doctor workforce in the region have been limited by a small number of medical schools with limited enrolments, international migration of graduates, poor geographic distribution of doctors, and insufficient data on medical schools. The goal of the Sub-Saharan African Medical Schools Study (SAMSS) is to increase the level of understanding and expand the baseline data on medical schools in the region.MethodsThe SAMSS survey is a descriptive survey study of Sub-Saharan African medical schools. The survey instrument included quantitative and qualitative questions focused on institutional characteristics, student profiles, curricula, post-graduate medical education, teaching staff, resources, barriers to capacity expansion, educational innovations, and external relationships with government and non-governmental organizations. Surveys were sent via e-mail to medical school deans or officials designated by the dean. Analysis is both descriptive and multivariable.ResultsSurveys were distributed to 146 medical schools in 40 of 48 Sub-Saharan African countries. One hundred and five responses were received (72% response rate). An additional 23 schools were identified after the close of the survey period. Fifty-eight respondents have been founded since 1990, including 22 private schools. Enrolments for medical schools range from 2 to 1800 and graduates range from 4 to 384. Seventy-three percent of respondents (n = 64) increased first year enrolments in the past five years. On average, 26% of respondents graduates were reported to migrate out of the country within five years of graduation (n = 68). The most significant reported barriers to increasing the number of graduates, and improving quality, related to infrastructure and faculty limitations, respectively. Significant correlations were seen between schools implementing increased faculty salaries and bonuses, and lower percentage loss of faculty over the previous five years (P = 0.018); strengthened institutional research tools (P = 0.00015) and funded faculty research time (P = 0.045) and greater faculty involvement in research; and country compulsory service requirements (P = 0.039), a moderate number (1-5) of post-graduate medical education programs (P = 0.016) and francophone schools (P = 0.016) and greater rural general practice after graduation.ConclusionsThe results of the SAMSS survey increases the level of data and understanding of medical schools in Sub-Saharan Africa. This data serves as a baseline for future research, policies and investment in the health care workforce in the region which will be necessary for improving health.

“Out of sight, out of mind”: Housestaff perceptions of quality‐limiting factors in discharge care at teaching hospitals

BACKGROUNDnImproving hospital discharge has become a national priority for teaching hospitals, yet little is known about physician perspectives on factors limiting the quality of discharge care.nnnOBJECTIVESnTo describe the discharge process from the perspective of housestaff physicians, and to generate hypotheses about quality-limiting factors and key strategies for improvement.nnnMETHODSnQualitative study with in-depth, in-person interviews with a diverse sample of 29 internal medicine housestaff, in 2010-2011, at 2 separate internal medicine training programs, including 7 different hospitals. We used the constant comparative method of qualitative analysis to explore the experiences and perceptions of factors affecting the quality of discharge care.nnnRESULTSnWe identified 5 unifying themes describing factors perceived to limit the quality of discharge care: (1) competing priorities in the discharge process; (2) inadequate coordination within multidisciplinary discharge teams; (3) lack of standardization in discharge procedures; (4) poor patient and family communication; and (5) lack of postdischarge feedback and clinical responsibility.nnnCONCLUSIONSnQuality-limiting factors described by housestaff identified key processes for intervention. Establishment of clear standards for discharge procedures, including interdisciplinary teamwork, patient communication, and postdischarge continuity of care, may improve the quality of discharge care by housestaff at teaching hospitals.

“Learning by Doing”—Resident Perspectives on Developing Competency in High-Quality Discharge Care

BackgroundReducing readmissions and post-discharge adverse events by improving the quality of discharge care has become a national priority, yet we have limited understanding about how physicians learn to provide high-quality discharge care.MethodsWe conducted in-depth, in-person interviews with housestaff physicians with qualitative analysis by a multi-disciplinary team using the constant comparative method to explore learning about high-quality discharge care as a systems-based practice and to identify opportunities to improve training around these concepts.ResultsWe analyzed interview transcripts from 29 internal medicine residents: 17 (59xa0%) were interns (PGY-2 or PGY-3), 12 (41xa0%) seniors, and 17 (59xa0%) were female. We identified a recurrent theme of lack of formal training about the discharge process, substantial peer-to-peer instruction, and “learning by doing” on the wards. Within this theme, we identified five specific concepts related to systems-based practice and high-quality discharge care which residents learned during residency: (1) teamwork and the interdisciplinary nature of discharge planning; (2) advanced planning strategies to anticipate challenges in the discharge process; (3) patient safety and the concept of a “safe discharge;” (4) patient continuity of care and learning from post-discharge outcomes and; (5) documentation of discharge plans as a valuable skill.ConclusionsDischarge care is an overlooked opportunity to teach concepts of systems-based practice explicitly as learning about discharge care is unstructured and individual experiences may vary considerably. Educational interventions to standardize learning about discharge care may improve the development of systems-based practice during residency and help improve the overall quality of discharge care at teaching hospitals.

Understanding Transitions in Care from Hospital to Homeless Shelter: a Mixed-Methods, Community-Based Participatory Approach

ABSTRACTBACKGROUNDCoordinated transitions from hospital to shelter for homeless patients may improve outcomes, yet patient-centered data to guide interventions are lacking.OBJECTIVESTo understand patients’ experiences of transitions from hospital to a homeless shelter, and determine aspects of these experiences associated with perceived quality of these transitions.DESIGNSMixed methods with a community-based participatory research approach, in partnership with personnel and clients from a homeless shelter.PARTICIPANTSNinety-eight homeless individuals at a shelter who reported at least one acute care visit to an area hospital in the last year.APPROACHUsing semi-structured interviews, we collected quantitative and qualitative data about transitions in care from the hospital to the shelter. We analyzed qualitative data using the constant comparative method to determine patients’ perspectives on the discharge experience, and we analyzed quantitative data using frequency analysis to determine factors associated with poor outcomes from patients’ perspective.KEY RESULTSUsing qualitative analysis, we found homeless participants with a recent acute care visit perceived an overall lack of coordination between the hospital and shelter at the time of discharge. They also described how expectations of suboptimal coordination exacerbate delays in seeking care, and made three recommendations for improvement: 1) Hospital providers should consider housing a health concern; 2) Hospital and shelter providers should communicate during discharge planning; 3) Discharge planning should include safe transportation. In quantitative analysis of recent hospital experiences, 44xa0% of participants reported that housing status was assessed and 42xa0% reported that transportation was discussed. Twenty-seven percent reported discharge occurred after dark; 11xa0% reported staying on the streets with no shelter on the first night after discharge.CONCLUSIONSHomeless patients in our community perceived suboptimal coordination in transitions of care from the hospital to the shelter. These patients recommended improved assessment of housing status, communication between hospital and shelter providers, and arrangement of safe transportation to improve discharge safety and avoid discharge to the streets without shelter.Coordinated transitions from hospital to shelter for homeless patients may improve outcomes, yet patient-centered data to guide interventions are lacking. To understand patients’ experiences of transitions from hospital to a homeless shelter, and determine aspects of these experiences associated with perceived quality of these transitions. Mixed methods with a community-based participatory research approach, in partnership with personnel and clients from a homeless shelter. Ninety-eight homeless individuals at a shelter who reported at least one acute care visit to an area hospital in the last year. Using semi-structured interviews, we collected quantitative and qualitative data about transitions in care from the hospital to the shelter. We analyzed qualitative data using the constant comparative method to determine patients’ perspectives on the discharge experience, and we analyzed quantitative data using frequency analysis to determine factors associated with poor outcomes from patients’ perspective. Using qualitative analysis, we found homeless participants with a recent acute care visit perceived an overall lack of coordination between the hospital and shelter at the time of discharge. They also described how expectations of suboptimal coordination exacerbate delays in seeking care, and made three recommendations for improvement: 1) Hospital providers should consider housing a health concern; 2) Hospital and shelter providers should communicate during discharge planning; 3) Discharge planning should include safe transportation. In quantitative analysis of recent hospital experiences, 44xa0% of participants reported that housing status was assessed and 42xa0% reported that transportation was discussed. Twenty-seven percent reported discharge occurred after dark; 11xa0% reported staying on the streets with no shelter on the first night after discharge. Homeless patients in our community perceived suboptimal coordination in transitions of care from the hospital to the shelter. These patients recommended improved assessment of housing status, communication between hospital and shelter providers, and arrangement of safe transportation to improve discharge safety and avoid discharge to the streets without shelter.

Understanding patient-centred readmission factors: a multi-site, mixed-methods study

Importance Patient concerns at or before discharge inform many transitional care interventions; few studies examine patients’ perceptions of self-care and other factors related to readmission. Objectives To characterise patient-reported or caregiver-reported factors contributing to readmission. Design, setting and participants Cross-sectional, national study of general medicine patients readmitted within 30u2005days at 12 US hospitals. Interviews included multiple-choice survey and open-ended survey questions of patients or their caregivers. Measurements Multiple-choice survey quantified post-discharge difficulty in seven domains of self-care: medication use, contacting providers, transportation, basic needs (eg, food and shelter), diet, social support and substance abuse. Open-ended responses were coded into themes that added depth to the domains above or captured additional patient-centred concerns. Results We interviewed 1066 readmitted patients. 91% reported understanding their discharge plan; however, only 37% reported that providers asked about barriers to carrying out the plan. 52% reported experiencing difficulty in ≥1 self-care domains ranging in frequency from 22% (diet) to 7% (substance use); 26% experienced difficulty in two or more domains. Among 508 patients (48% overall) who reported no difficulties in these domains, two-thirds either could not attribute their readmission to any specific difficulty (34%) or attributed their readmission to progression or persistence of their disease despite following their discharge plan (31%). Only 20% attributed their readmission to early discharge (8%), poor-quality hospital care (6%) or issues such as inadequate discharge instructions or follow-up care (6%). Limitations The study population included only patients readmitted at academic medical centres and may not be representative of community-based care. Conclusion Patients readmitted within 30u2005days reported understanding their discharge plans, but frequent difficulties in self-care and low anticipatory guidance for resolving these issues after discharge.

Features of High Quality Discharge Planning for Patients Following Acute Myocardial Infarction

ABSTRACTBACKGROUNDHospital discharge planning is required as a Medicare Condition of Participation (CoP), and is essential to the health and safety for all patients. However, there have been no studies examining specific hospital discharge processes, such as patient education and communication with primary care providers, in relation to hospital 30-day risk standardized mortality rates (RSMRs) for patients with acute myocardial infarction (AMI).OBJECTIVETo identify hospital discharge processes that may be associated with better performance in hospital AMI care as measured by RSMR.DESIGNWe conducted a qualitative study of U.S. Hospitals, which were selected based on their RSMR reported by the Centers for Medicare & Medicaid Services (CMS) Hospital Compare website for the most recent data available (January 1, 2005 – December 31, 2007). We selected hospitals that ranked in the top 5xa0% and the bottom 5xa0% of RSMR for the two consecutive years. We focused on hospitals at the extreme ends of the range in RSMR, known as deviant case sampling. We excluded hospitals that did not have the ability to perform percutaneous coronary intervention in order to decrease the heterogeneity in our sample.PARTICIPANTSParticipants included key hospital clinical and administrative staff most involved in discharge planning for patients admitted with AMI.METHODSWe conducted 14 site visits and 57 in-depth interviews using a standard discussion guide. We employed a grounded theory approach and used the constant comparative method to generate recurrent and unifying themes.KEY RESULTSWe identified five broad discharge processes that distinguished higher and lower performing hospitals: 1) initiating discharge planning upon patient admission; 2) using multidisciplinary case management services; 3) ensuring that a follow-up plan is in place prior to discharge; 4) providing focused education sessions for both the patient and family; and 5) contacting the primary care physician regarding the patient’s hospitalization and follow-up care plan.CONCLUSIONComprehensive and more intense discharge processes that start on admission continue during the patient’s hospital stay, and follow up with the primary care physician within 2xa0days post-discharge, may be critical in reducing hospital RSMR for patients with AMI.

Social accountability in health professionals' training

With the 100th anniversary of Flexner’s seminal report on medical education, The Lancet published guidelines by a global independent Commission that aimed to establish a 21st-century vision for the education of health professionals. As young doctors, we applaud the Commission for moving beyond professional silos to new models of interprofessional collaboration. But there should be more emphasis on service and social mission in health professionals’ training. WHO defi nes the social accountability of medical training as “the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve”. Students entering the health professions have strong ideals that must be fostered during training and sustained within systems that encourage us to be change-agents in local and global contexts. Such education must go beyond care for the individual to instil the importance of community advocacy and the ethic of practising in areas of the greatest need. Unfortunately, that goal is far away. Economic factors, such as the high cost of medical education and the commoditisation of health care, have disincentivised practitioners from entering much-needed primary care. In developed countries, underserved areas lack providers; in developing countries, the brain drain has resulted in far worse shortages. Moreover, the existing education that places disproportionate focus on basic science unbalances the curriculum, with over 90% of students reporting that they are not suffi ciently trained in public health and problems facing their community. As students go through training, idealism erodes, with an accompanying decline in service orientation and empathy for patients. The centennial of Flexner’s report is the time to make bold changes and redirect the focus of health professionals’ education towards social accountability. Using the training of doctors as our example, we propose fi ve steps for every medical school and healthprofessional training programme to help align their training with societal need. First, an explicit social mission needs to be established. A recent report on US medical schools showed that having social accountability as the guiding principle aff ected every step of training, from recruitment to curriculum to career. Regulatory bodies should measure social accountability as a metric for excellence and accreditation. Second, community learning and service should be integrated into the curriculum. Students who spend more time in community settings have a much higher rate of returning there to practise. For doctors to truly advocate for their communities, an irreplaceable part of training needs to be understanding and addressing community concerns. Third, the importance of primary care deserves particular emphasis. Although the centrality of primary health care has been recognised since the declaration of Alma-Ata over 30 years ago, too few young doctors are entering primary care. Some institutions, such as the Walter Sisulu Medical School in South Africa, teach fi rst-year students to incorporate community-oriented primary care principles by visiting family homes, traditional healers, and community health centres. Most graduates are practising primary care in rural and peri-urban areas. Fourth, there needs to be a service option in exchange for free medical education. The concept of debt repayment in exchange for service has existed in virtually every country as compulsory national service or loan repayment options. Early data from compulsory programmes in 70 countries showed promising results. One example is Cuba’s Latin American School