Stephen A. Margolis

How can experience in clinical and community settings contribute to early medical education? A BEME systematic review #

Review date: Review period January 1992–December 2001. Final analysis July 2004–January 2005. Background and review context: There has been no rigorous systematic review of the outcomes of early exposure to clinical and community settings in medical education. Objectives of review: Identify published empirical evidence of the effects of early experience in medical education, analyse it, and synthesize conclusions from it. Identify the strengths and limitations of the research effort to date, and identify objectives for future research. Search strategy: Ovid search of: BEI, ERIC, Medline, CINAHL and EMBASE Additional electronic searches of: Psychinfo, Timelit, EBM reviews, SIGLE, and the Cochrane databases. Hand-searches of: Medical Education, Medical Teacher, Academic Medicine, Teaching and Learning in Medicine, Advances in Health Sciences Education, Journal of Educational Psychology. Criteria: Definitions: • Experience: Authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional. • Early: What would traditionally have been regarded as the preclinical phase, usually the first 2 years. Inclusions: All empirical studies (verifiable, observational data) of early experience in the basic education of health professionals, whatever their design or methodology, including papers not in English. Evidence from other health care professions that could be applied to medicine was included. Exclusions: Not empirical; not early; post-basic; simulated rather than ‘authentic’ experience. Data collection: Careful validation of selection processes. Coding by two reviewers onto an extensively modified version of the standard BEME coding sheet. Accumulation into an Access database. Secondary coding and synthesis of an interpretation. Headline results: A total of 73 studies met the selection criteria and yielded 277 educational outcomes; 116 of those outcomes (from 38 studies) were rated strong and important enough to include in a narrative synthesis of results; 76% of those outcomes were from descriptive studies and 24% from comparative studies. Early experience motivated and satisfied students of the health professions and helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills. There were outcomes for beneficiaries other than students, including teachers, patients, populations, organizations and specialties. Early experience increased recruitment to primary care/rural medical practice, though mainly in US studies which introduced it for that specific purpose as part of a complex intervention. Conclusions: Early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It has potential benefits for other stakeholders, notably teachers and patients. It can influence career choices.

Indigenous Australians’ understandings regarding mental health and disorders

The purpose of the present paper was to determine what is currently documented about Indigenous Australians’ understandings of mental health and mental disorders through a meta-synthesis of peer-reviewed qualitative empirical research. The following databases were electronically searched (1995–April 2006): AOA-FT and AIATSIS, Blackwell Synergy, CINAHL and Pre CINHAL, Health source: nursing/academic edition, Medline, Proquest health and medical complete, PsycInfo, Science Direct, Synergy and HealthInfoNet. Eligible studies were those written in English and published in peer-reviewed journals, empirical studies that considered Indigenous peoples understandings of mental health and provided details on methodology. Five articles from four qualitative studies met these criteria. Meta-ethnography was used to identify common themes emerging from the original studies. Reciprocal translation was used to synthesize the findings to provide new interpretations extending beyond those presented in the original studies. An overarching theme emerged from the synthesis: the dynamic interconnectedness between the multi-factorial components of life circumstances. Reciprocal translations and synthesis regarding Indigenous understandings of mental health and illness resulted in five themes: (i) culture and spirituality; (ii) family and community kinships; (iii) historical, social and economic factors; (iv) fear and education; and (v) loss. The application of a meta-synthesis to these qualitative studies provided a deeper insight into Indigenous peoples understandings of mental health and illness. The importance of understanding Indigenous descriptions and perceptions of mental health issues is crucial to enable two-way understandings between Indigenous peoples constructs of wellness and Western biomedical diagnostic labels and treatment pathways for mental disorders and mental health problems.

What has changed in the evidence for early experience? Update of a BEME systematic review

Background: We previously reviewed evidence published from 1992 to 2001 concerning early experience for healthcare undergraduates (Dornan T, Littlewood S, Margolis S, Scherpbier A, Spencer J, Ypinazar V. 2006. How can experience in clinical and community settings contribute to early medical education? A BEME systematic review. Med Teach 28:3–18). This subsequent study reviews evidence published from 2002 to 2008. Aims: Identify changes in the evidence base; determine the value of re-reviewing; set a future research agenda. Methods: The same search strategy as in the original review was repeated. Newly identified publications were critically appraised against the same benchmarks of strength and educational importance. Results: Twenty-four new empirical studies of early authentic experience in education of health professionals met our inclusion criteria, yielding 96 outcomes. Sixty five outcomes (from 22 studies) were both educationally important and based on strong evidence. A new significant theme was found: the use of early experience to help students understand and align themselves with patient and community perspectives on illness and healthcare. More publications were now from outside Europe and North America. Conclusions: In addition to supporting the findings of our original review, this update shows an expansion in research sources, and a shift in research content focus. There are still questions, however, about how early authentic experience leads to particular learning outcomes and what will make it most educationally effective.

Study Protocol - Alcohol Management Plans (AMPs) in remote indigenous communities in Queensland: Their impacts on injury, violence, health and social indicators and their cost-effectiveness

BackgroundIn 2002/03 the Queensland Government responded to high rates of alcohol-related harm in discrete Indigenous communities by implementing alcohol management plans (AMPs), designed to include supply and harm reduction and treatment measures. Tighter alcohol supply and carriage restrictions followed in 2008 following indications of reductions in violence and injury. Despite the plans being in place for over a decade, no comprehensive independent review has assessed to what level the designed aims were achieved and what effect the plans have had on Indigenous community residents and service providers. This study will describe the long-term impacts on important health, economic and social outcomes of Queensland’s AMPs.Methods/DesignThe project has two main studies, 1) outcome evaluation using de-identified epidemiological data on injury, violence and other health and social indicators for across Queensland, including de-identified databases compiled from relevant routinely-available administrative data sets, and 2) a process evaluation to map the nature, timing and content of intervention components targeting alcohol. Process evaluation will also be used to assess the fidelity with which the designed intervention components have been implemented, their uptake and community responses to them and their perceived impacts on alcohol supply and consumption, injury, violence and community health. Interviews and focus groups with Indigenous residents and service providers will be used. The study will be conducted in all 24 of Queensland’s Indigenous communities affected by alcohol management plans.DiscussionThis evaluation will report on the impacts of the original aims for AMPs, what impact they have had on Indigenous residents and service providers. A central outcome will be the establishment of relevant databases describing the parameters of the changes seen. This will permit comprehensive and rigorous surveillance systems to be put in place and provided to communities empowering them with the best credible evidence to judge future policy and program requirements for themselves. The project will inform impending alcohol policy and program adjustments in Queensland and other Australian jurisdictions.The project has been approved by the James Cook University Human Research Ethics Committee (approval number H4967 & H5241).

Structured assessment using multiple patient scenarios by videoconference in rural settings

Context  The assessment blueprint of the Australian College of Rural and Remote Medicine postgraduate curriculum highlighted a need to assess clinical reasoning. We describe the development, reliability, feasibility, validity and educational impact of an 8‐station assessment tool, StAMPS (structured assessment using multiple patient scenarios), conducted by videoconference.

Aeromedical Retrieval for Critical Clinical Conditions: 12 Years of Experience with the Royal Flying Doctor Service, Queensland, Australia

BACKGROUND The Royal Flying Doctor Service (RFDS) has been providing emergency aeromedical retrieval services in Queensland, Australia since 1928. STUDY OBJECTIVES This article details service and delivery structure plus a description of 12 years of experience managing patients with critical clinical conditions. METHODS This study is a retrospective longitudinal analysis of the demographics and diagnostic classification of all cases of critical clinical severity conducted March 1, 1994 through February 28, 2006. RESULTS There were a total of 72,054 retrievals, with trauma the single most common clinical diagnosis. There were 4259 retrievals for patients with critical clinical conditions (6%). The most common categories of clinical diagnosis were: trauma with 1493 (35.1%), respiratory diseases 1386 (32.5%), and circulatory diseases 908 (21.3%). Trauma accounted for 69 of the 90 (77%) primary retrievals from locations without health care facilities. The death rate in transport was 1%, with most of these involving males from locations with minimal health facilities. CONCLUSION The RFDS in Queensland is an effective provider of fixed-wing aeromedical retrieval services, operating in an unusual environment with vast distances, low population density, and a high number of Indigenous people.

Coming to an ethics of research practice in a remote Aboriginal Australian community

Abstract Background: This paper identifies the latent opportunities and challenges inherent in the formative stages of a project that was resumed after partial completion by other on-the-ground research teams. Methods: Grounded theory methods were used to analyse project documentation from previous research teams and to generate new process-oriented data. Results: The intention of all research teams was moving towards Engaging in Community-Based Participatory Research; this was conceptually identified as the core category. The social process involved in achieving community engagement practice was named Coming to an Ethics of Practice. Four different facets comprised the core category: Developing meaningful relationships; being reflective; recognising difference; and making research relevant. Conclusions: To achieve mutually beneficial outcomes, researchers conducting community-based research with Aboriginal people must implement strengths-based approaches to realise ethically sound research; prioritise the relevance of the research to the daily lives, needs and aspirations of those with whom they work; and in doing so, remain cognisant of their own philosophical position and context in which the research is located.

Identification of best evidence in medical education. Case study

Aim: Compare how different researchers performed in screening for informative evidence about medical education. Method: Six researchers with three different levels of involvement in a systematic literature review screened articles by title and (where available) abstract, and then by reading articles they had selected in full text. The reference standard was a consensus decision to include or exclude the article in the final analysis, whose results are published elsewhere. Results: The single screener most involved in the literature search, who was also the most junior member of the topic review group, achieved a sensitivity approaching 100% and a specificity of 98–100% for informative articles. She far outperformed the other researchers, all of whom had as much or more topic knowledge and greater research experience. Conclusion: It was not possible to improve on the performance of the single motivated and capable primary screener and trying to do so increased the number of uninformative articles retrieved. One interpretation is that the primary searcher was more practiced and focused on the task than her more senior colleagues, yet they tended to become worse rather than better with practice. The fact that a well informed but relatively naïve person consistently outperformed her more “expert” colleagues might suggest an alternative explanation: Given the patchy standard and qualitative nature of the evidence, perhaps experts found it harder than a novice to make reliable choices, in which case their unreliable performance reflects the nature of present day education evidence. This case study illustrates the value of quality assuring the article selection process. Given the amount of disagreement uncovered by the study, we suggest that consensus between reviewers is an important reference standard against which the performance of any single primary screener should be checked.

'Sly grog' and 'homebrew': a qualitative examination of illicit alcohol and some of its impacts on Indigenous communities with alcohol restrictions in regional and remote Queensland (Australia)

BackgroundIndigenous communities in Queensland (Australia) have been subject to Alcohol Management Plans since 2002/03, with significant penalties for breaching restrictions. ‘Sly grog’ and ‘homebrew’ provide access to alcohol despite restrictions. This paper describes how this alcohol is made available and the risks and impacts involved. In affected towns and communities across a large area of rural and remote Queensland, interviews and focus groups documented experiences and views of 255 long-standing community members and service providers. Using an inductive framework, transcribed interviews were analysed to identify supply mechanisms, community and service provider responses and impacts experienced.Results‘Homebrew’ was reportedly manufactured in just a few localities, in locally-specific forms bringing locally-specific harms. However, ‘sly grog’ sourced from licensed premises located long distances from communities, is a widespread concern across the region. ‘Sly grog’ sellers circumvent retailers’ takeaway liquor license conditions, stockpile alcohol outside restricted areas, send hoax messages to divert enforcement and take extraordinary risks to avoid apprehension. Police face significant challenges to enforce restrictions. On-selling of ‘sly grog’ appears more common in remote communities with total prohibition. Despite different motives for involvement in an illicit trade ‘sly grog’ consumers and sellers receive similar penalties.ConclusionsThere is a need for: (a) a more sophisticated regional approach to managing takeaway alcohol sales from licensed suppliers, (b) targeted penalties for ‘sly grog’ sellers that reflect its significant community impact, (c) strategies to reduce the demand for alcohol and (d) research to assess the effects of these strategies in reducing harms.

A longitudinal observation study assessing changes in indicators of serious injury and violence with alcohol controls in four remote indigenous Australian communities in far north Queensland (2000–2015)

AbstractBackgroundLegal restrictions on alcohol availability have been used to address violence and injury in the world’s remote Indigenous communities. In Australia, alcohol management plans (AMPs) were implemented by the Queensland Government in 2002. This study reports changes in indicators of alcohol-related violence and injury in selected communities.MethodsDesign and setting: A longitudinal observational study was conducted in four Aboriginal and Torres Strait Islander (Indigenous) communities in Cape York, far north Queensland. All communities are similarly-isolated from population centres where alcohol is available.Data: For 2000 to 2015 inclusive: 1019 Royal Flying Doctor Service aeromedical trauma retrievals; 5641 Queensland Police Service records of unique assault occurrences, including 2936 involving alcohol; and records for 2741 unique assault victims were examined. Data analysis: Rates (per 1000 population) of trauma retrievals, assault occurrences and assault victims (per 1000 population) were compared across three policy phases.Phase 1: 2000 to 2008. Initial restrictions on possession and consumption of alcohol in ‘restricted areas’ were implemented during 2002–2003.Phase 2: 2009 to 2012. All alcohol was prohibited in three study communities and its legal availability limited in the fourth from 2009.Phase 3: 2013 to 2015. Government reviews of AMP policies in light of legal challenges and community responses characterise this phase.ResultsCompared with Phase 1, in Phase 2 retrieval rates declined by − 29.4%, assault occurrences by − 34.1% with less than one-third involving alcohol, and assault victims by − 21.1%, reaching historically low levels in 2010–2012. These reductions did not continue consistently. Compared with Phase 1, in Phase 3 retrieval rates, assault occurrence rates and assault victim rates declined by somewhat lesser amounts, − 13.9%, − 15.0% and − 13.4%, respectively. In Phase 3, the proportion of assault occurrences involving alcohol in communities 2, 3 and 4 rose towards pre-2008 levels.ConclusionsEarly successes of these controversial alcohol restrictions are jeopardised. Indicators of violence and injury appear to be rising once more in some AMP communities. Importantly, rates have not generally exceeded the highest levels seen in Phase 1. Fresh policy action is required with rigorous monitoring to prevent erosion of initial important successes.